Building resilience: how

local partnerships are

supporting children and

young people’s mental

health and emotional

wellbeing

2020

NATALIE PARISH, BETH SWORDS AND LUCY MARKS

Contents Executive summary ............................................................................................................................... 2

Introduction .......................................................................................................................................... 7

Purpose of the research and methodology ........................................................................................... 7

Significant policy developments in children and young people’s mental health .................................. 8

The current national context for supporting children and young people’s mental health ................. 11

Rising demand for mental health support for children and young people ..................................... 12

Why is demand for mental health support for children and young people rising in England? ... 13

Why are referrals rising more quickly than prevalence levels? ................................................... 15

Insufficient and unequal funding .................................................................................................... 16

Unmet need .................................................................................................................................... 19

Beyond funding – systemic challenges to delivering effective support .............................................. 20

System complexity and fragmentation ........................................................................................... 20

Capacity and wellbeing of mental health professionals .................................................................. 20

Not enough investment in or focus on effective early intervention ............................................... 21

How local partnerships are overcoming these challenges .................................................................. 21

Leadership and vision ..................................................................................................................... 23

Self-reflective partnership .............................................................................................................. 24

Integrated commissioning .............................................................................................................. 25

Working with children and young people ....................................................................................... 27

Promoting good mental health ....................................................................................................... 29

Developing the children’s workforce .............................................................................................. 31

Embedded CAMHS .......................................................................................................................... 34

Supporting families ......................................................................................................................... 35

Creative approaches to managing risk ............................................................................................ 36

Looking ahead – enabling more effective local partnership working.................................................. 38

Recommendations for national government (DfE, DHSC and NHS) .................................................... 38

Annex A – Profiles of fieldwork areas ................................................................................................. 40

Executive summary Too many children and young people nationally do not receive the support they need to improve

their mental health and wellbeing. There is ample evidence that, despite increased investment in,

and policy focus on, mental health services for children and young people, the numbers of children

and young people requiring support are going up. Thresholds for accessing support remain high,

waiting times are long and there is significant inequity in provision between different local areas.

The purpose of this research is, firstly, to explore some of the factors which are contributing to this

nationally challenging context and, secondly, to develop an evidence base for how local government

and its partners can work most effectively together to deliver a coherent and joined-up offer of

support for children and young people’s mental health. The research is based on a review of the

existing evidence base, workshops with around 80 participants from councils and their partners in

health and in-depth engagements with eight fieldwork areas.

The most recent data on the prevalence of diagnosable mental health conditions shows that 11.2

per cent of the 5 to 15 population has a mental health condition – up from 9.6 per cent in 2004. The

prevalence of mental health conditions rises with age, up to 16.9 per cent for 17 to 19-year olds.1 At

the same time referrals to Child and Adolescent Mental Health services (CAMHS) have increased

even more rapidly – by around 26 per cent in five years according to recent data.2

Both qualitative and qualitative evidence points to some of the factors which may be contributing to

this rise in prevalence: increasing levels of poverty among children and young people; the growth in

Special Education Needs; rising levels of family dysfunction possibly associated with pressures on

housing, employment and other societal factors; and pressures on young people which contribute to

anxiety including social media and an increasingly academic and examinations-oriented curriculum.

However, demand for support is growing more quickly than the underlying prevalence. This speaks

to the increased awareness of mental health issues in children and young people; rising levels of

lower-level mental health needs which would not classify as a diagnosable condition; and to the

diminished capacity of universal services, after a prolonged period of austerity, to support the

mental health needs without recourse to specialist support.

Expenditure on mental health has grown over recent years, in response to increased funding

delivered by Future in Mind. Nonetheless, children’s mental health remains significantly

underfunded compared with either children’s physical health or adults’ mental health. Moreover,

there remain striking differences in expenditure and service provision between different local areas.

Expenditure on CAMHS services ranges from £9 per capita in the lowest spending CCG up to £162

per capita in the highest.3 Reported spend on lower level mental health services shows an even

bigger range, from £0.26 to £173.

A limited finance data collection exercise from the fieldwork areas taking part in this research

showed that around three quarters of funding came from CCGs and around 71 per cent of

expenditure was allocated to CAMHS. Over half of the expenditure on children’s mental health was

spent on targeted services and, in terms of the THRIVE framework categories, around 40 per cent

was spent on ‘getting help’.

1 Mental Health in Children and Young People in England 2017, NHS digital, November 2018 2 Access to children and young people’s mental health services 2018, Education Policy Institute, October 2018 3 Children’s Commissioner, Children’s Mental Health Briefing, A briefing by the Office of the Children’s Commissioner in England, November 2018

Evidence compiled by the Children’s Commissioner, the Education Policy Institute and others on

levels of unmet need is compelling. Our research highlights three systemic challenges, beyond the

issues of underfunding, that were impeding the most effective use of the resources and capacity

available. The first is the complexity and fragmentation of the system contributing to a lack of clear

national direction. The second is the capacity and wellbeing of those delivering mental health

support, reflecting both staff shortages in key professions such as educational psychology and

children’s psychologists, the lack of join up between these professions, and the reduced capacity of

staff in universal services such as schools or health visiting.

The final systemic issue frustrating the more effective delivery of mental health and wellbeing

support is the lack of focus on early intervention. Arguably, the orientation of the whole system,

from where funding is directed, through how clearly responsibilities are described, to the targets

that are set, incentivise a set of behaviours that prioritise specialist and complex treatment at the

expense of earlier intervention and prevention. It is revealing that all the national targets which

relate to children’s mental health revolve around access to specialist treatment rather than

outcomes experienced by children and young people.

However, despite the very challenging national context for supporting children and young people’s

mental health and wellbeing, our fieldwork in eight contrasting local areas shows just how much

local government, working closely with its key partners, can do to mitigate the effects of some of

these challenges and deliver better outcomes for children and young people.

Throughout our fieldwork engagements, nine key themes, or enablers, recurred as critical elements

in establishing an effective partnership-based approach to supporting children and young people’s

mental health, which in turn contributed to three overarching ways of working. Where these were

securely in place, local areas felt that they were able to deliver better and more timely access to

support, earlier intervention and prevention and more efficient use of resources. The nine key

enablers are graphically represented below:

Leadership and vision starts with political leaders who are prepared to champion and advocate for

children’s and young people’s mental health, and who can orient their vision for children’s mental

health within their overarching ambitions for the community, be that in terms of employment,

learning or health. Where elected members create a political environment in which children and

young people’s mental health is championed, there is an equally important role for senior officers

within children’s services and senior leaders within the CCG to create the operational environment

in which partnership working for children’s mental health can flourish. All the fieldwork areas had

adopted the THRIVE framework, which was jointly developed by The Anna Freud Centre and

Tavistock and Portman NHS Foundation Trust. It was proving a powerful vehicle for bringing partners

together with a shared strategic vision and a common language for how they would achieve that

vision.

Strong self-reflective partnerships combined a robust governance structure with a clear agreement

of the outcomes the partnership was seeking to achieve. The most effective partnerships were

characterised by trusting relationships, a diverse set of providers and partners represented,

familiarity in working and problem solving together, time taken to reflect on what had worked and

what had not; and meaningful dialogue about how to improve.

Integrated commissioning was facilitated through shared commissioning plans and objectives, and

in many cases a single commissioning post or team working across both the council and the CCG.

Some local areas had pooled their budgets under section 75 agreements to allow each partner to

spend and discharge the responsibilities of the other. Integrated commissioning, however, is not

important as an end in itself, but because it enables bolder decisions to be made about how money

is spent and creates the conditions in which the total investment in children’s mental health is

maximised.

Working with young people in a meaningful way was essential to shaping an offer to meet their

needs. Engaging young people in designing and evaluating services tended to be most successful

when it permeated each level of the system, from service user feedback up to shaping whole-system

priorities, and when it was part and parcel of how partners worked together, rather than a one-off

exercise. Local areas had also focused on developing a better understanding of the lived experience

of young people with mental health needs and drawing on the skills and capacity of young people as

peer mentors.

Promoting good mental health for all children and young people is central to the concept of earlier

intervention and prevention. Fieldwork areas were focusing on the role of children’s centres,

perinatal services and early years settings in supporting parents and professionals to understand

young children’s emotional development and implement proven strategies for promoting ongoing

good mental health. They were also working with schools to embed positive ways of promoting

mental health within the curriculum, within pedagogy, and within approaches to behaviour

management. Normalising periods of emotional difficulty for children and young people; maximising

the opportunities for engaging in positive activities and attending to the link between physical and

mental health all formed important elements in promoting good mental health.

Developing the children’s workforce so that ‘children’s mental health is everyone’s business’,

involved putting in place training, advice and support so that staff working in schools, colleges,

nurseries, youth services and frontline health roles are equipped with the skills and techniques to

begin to have supportive conversations about mental health with children and young people. Local

areas spoke about the importance of reducing professional anxiety around children’s mental health,

providing practical examples of what professionals could do within the course of their day to day

work, and knowing what to look for which might indicate that more specialist help is needed.

Embedded CAMHS where specialist mental health expertise is integrated within the delivery of

other key services enables a very different model of delivering targeted and specialist mental health

interventions, with a focus on working across a broader group of professionals to develop a plan for

intervention and delivering in settings that are closer to children and young people. This way of

working depends on the development of trusting relationships, fostered through co-location, time

spent thinking and working together, joint visits and prereferral discussions.

Supporting families holistically enables professionals to attend to the family context in which good

or poor mental health occurs. The prevalence data shows a strong correlation between parental

mental health and child mental health, and there is now a growing body of evidence of how

important it is to address parental conflict in order to effect change in child mental health and

behaviour. Many of the areas engaged in this research were beginning to explore what holistic

family-based mental health support should look like. Often this was spear-headed by early help

services which have strengths-based holistic family work in their DNA. However, local partnerships

were also frank in highlighting the big gap that still exists with adults’ mental health commissioning

and expressed an appetite to help shape and influence that to more routinely consider the needs of

families.

Creative solutions to managing risk are essential to supporting children and young people with very

complex mental health or emotional challenges and who are not progressing well with traditional

CAMHS interventions. Many of the local areas that we engaged were therefore looking at different

ways of collectively managing the risk of more complex cases. Historically these children and young

people might have been seen as the responsibility of specialist services, but with the introduction of

the THRIVE framework local partnerships were increasingly looking at how a variety of services and

partners might come together to enable, and trust, young people to look after themselves and

successfully manage their ongoing mental health condition.

The nine key enablers provide an insight into how effective local partnerships can work together to

improve the mental health and emotional wellbeing of all children and young people, act early to

resolve issues before they escalate, and provide more timely, accessible and joined-up care for those

with more complex needs. There is clearly a lot that local government and its partners can do, even

within the limitations of the current system, to improve mental health and emotional wellbeing for

children and young people.

However, there is a limit to what local government and its partners can do unaided. To turn around a

system plagued by a history of underfunding, shortages in the key workforces, rapidly rising demand

and a weak focus on early intervention requires concerted and coordinated action at a national

level. This is not solely about making more funding available, although that undoubtedly is needed,

but about making the most of the resources currently in the system. The following

recommendations for national government to work with local government and its partners are made

with that aim in mind:

1. Set clear targets for the whole system which incentivise the investment in earlier support

and prevention and focus on achieving better mental health outcomes for all children and

young people.

2. Develop a consistent outcomes-focused dataset, to be used across local government and

CCGs to measure progress against the targets.

3. Set clearer expectations around strategic cooperation between CCGs and local government

for children’s mental health and give greater leverage to health and wellbeing boards to

ensure that this is acted upon.

4. Move away from pilot funding and ring-fenced grants to recurrent funding, giving more

flexibility to local partnerships to develop solutions that build on their local context.

5. Develop clearer specifications for the effective commissioning of universal mental health

provision.

6. Create stronger expectations of joined up planning, commissioning and delivery between

children and adults’ mental health, with a core focus on supporting families holistically and

managing transition for young people between adults’ and children’s services.

7. Review the sufficiency of the national workforce for children’s psychology (EPs, CAMHS,

and others) and create opportunities for joint professional training between educational

psychologists and CAMHS clinicians.

8. Consider how the national curriculum and school accountability system might be geared to

encourage more secure development of good mental health and to minimise the current

rise in anxiety-related issues.

9. Research and promote best practice in working with the cohort of very hard to place

adolescents and those with the most complex needs being supported in their communities,

including developing a best practice offer of training and support for foster carers.

Introduction Mental health and the emotional wellbeing of children and young people has been rising up the

national agenda for the past decade. This is being driven by increasing demand for support, but also

by an awareness that the current system does not have the capacity to keep pace with this demand.

According to the latest research commissioned by NHS digital, mental health problems affect one in

eight children and young people between the ages of 5 and 19, with numbers rising during teenage

years with around 17 per cent of 17 to 19-year olds experiencing diagnosable mental health

problems.4 Yet only a quarter of school-age children with a diagnosable problem receive any

intervention at all, despite most parents of these children seeking professional advice.5 It is telling

that this piece of research for the Local Government Association is published shortly after the

OECD’s Programme for International Student Assessment found that 15 year olds in the UK

experience considerably lower levels of satisfaction with their lives than the OECD average.6

Thanks to the painstaking research of key advocates for children’s mental health such as the

Children’s Commissioner, Young Minds, the Education Policy Institute, the Centre for Mental Health,

the Mental Health Foundation and the NSPCC to name but a few, we now know much more than we

did five years ago about the levels of unmet need, the inequality in accessing support and the

bottlenecks in vital services that leave too many vulnerable children waiting too long for the help

they need. This research does not aim to revisit the ground covered so well by others. Instead the

purpose of this work is to build on the evidence base that has been constructed on the nature of the

challenge and then ask the question, what can local government and its partners do to address some

of these systemic issues? The second question is what more should national government be doing to

support local partnerships in this endeavour?

Purpose of the research and methodology In May 2019 Isos Partnership was commissioned by the Local Government Association to carry out a

focused piece of research looking at how local government and its partners can work most

effectively together to support children and young people’s mental health and emotional wellbeing.

The specific focus of the research has been to:

• Better understand the funding landscape for children and young people’s mental health.

• Identify the issues that councils are experiencing in their support of children and young

people’s mental health and wellbeing.

• Exemplify good practice in how local government can support children and young people

with mental health needs and contribute to reducing escalation to specialist services.

• Contribute to a local government led set of recommendations to improve the support of

young people’s mental and emotional wellbeing to inform future policy development.

We have employed a mixed qualitative and quantitative methodology for this project. In phase one

we carried out a short literature review to understand recent changes in policy and the impact these

have had on the system. We also considered the available data, much of which has been collected

4 NHS Digital, 2018, Mental health of children and young people in England, 2017 5 Khan, 2016, Missed opportunities: a review of recent evidence into children and young people’s mental health, Centre for Mental Health 6 OECD, PISA 2018 Results, Combined Executive Summaries

through Freedom of Information requests, to build a nationwide picture of how well the mental

health needs of children and young people are being supported.

In phase two we invited representatives from all local authorities and key partners such as CCGs and

CAMHS providers to attend one of two workshops (one in the North of England and one in the

South) to explore both the challenges and opportunities in delivering support to children and young

people with mental health needs. The workshops were attended by a total of 80 participants.

In phase three we then conducted in-depth fieldwork visits to eight different local areas and also

carried out interviews with a small number of experts who could provide a national perspective on

the issues. The purpose of the fieldwork phase was to identify examples of good practice in how

local government and its partners can work effectively together to support children and young

people’s mental health. We invited local areas which felt that they had interesting and effective

work to showcase to put themselves forward. The sample was therefore deliberately skewed

towards those areas which believed they had been relatively more successful in combatting some of

the challenges associated with delivering good provision for children and young people’s mental

health. However, we took care to make sure that there was a balance in the sample between urban

and rural areas, small and large councils, council type (counties, boroughs, metropolitans and

unitaries), deprivation and political control. The final sample of eight councils which took part in the

fieldwork phase were Bedford, Camden, Cornwall, Dorset, Hertfordshire, Isles of Scilly, Liverpool and

Salford. We are extremely grateful to these local areas for the time they have given in contributing

to this research. A short profile of support for children and young people’s mental health and

emotional wellbeing in each area is included at annex A, and good practice vignettes from the

fieldwork areas illustrate the key findings from the research.

In each of the fieldwork areas we spoke to a wide range of local officers, partners and providers. We

asked each local partnership to put together a programme of the people who would give us the

greatest insight into the areas of innovative practice, as well as the challenges, experienced in their

local area. The precise cast list of those who took part therefore differed to some extent between

local areas. Over the course of all eight fieldwork engagements we spoke to a selection of:

• Senior council leaders, for example the Lead Member, Director of Children’s Services,

Director of Public Health and relevant Assistant Directors;

• Commissioning leads for children’s mental health;

• Relevant council heads of service (for example early help, children’s and adult social care,

SEND or Principal Educational Psychologist);

• Those leading teams which make a significant contribution to support emotional wellbeing,

for example YOS, youth services, troubled families or children’s centres;

• Head of finance for children’s services;

• Key partners including CCG commissioners, representatives of CAMHS services, and where

possible representatives from schools, GPs and the VCS; and

• Children and young people.

This report aims to bring together the findings of all three phases of this research.

Significant policy developments in children and young people’s

mental health The last decade has been marked by a rising awareness of the difficulties for children and young

people in accessing good quality support for their mental health and emotional wellbeing in a timely

way. There have, therefore, been successive policy initiatives designed to increase capacity for, and

access to, mental health support and provision. These policy developments have both tried to

expand the support offered by universal services, in particular schools and colleges, to create a

platform for early intervention in mental health, while in tandem investing to increase capacity at

more specialist levels of intervention, particularly CAMHS. This vision to achieve distributed

responsibility throughout the continuum of support is crucial in getting to a position where extreme

pressures on capacity are alleviated. However, despite the thrust of policy over recent years, the

system still has further to go.

Since 2011, schools have been increasingly encouraged to develop their capacity to support young

people’s mental health, by training staff or reshaping roles to include responsibility for mental

health. This shift towards a more graduated response across the system, beyond specialist services,

was prompted in 2011 by the Government strategy No Health Without Mental Health accompanied

by the Implementation Framework published in July 2012. This was further emphasised in January

2014, with the publication of Closing the Gap: priorities for essential change in mental health by the

Department of Health. Closing the Gap built on the 2011 strategy with greater urgency given the

context of growing backlogs and waiting times for CAMHS. Closing the Gap, as with previous

strategies, strongly emphasises the role of schools in needs identification and early intervention to

prevent possible escalation to specialist services. It also looks at how to improve access to

psychological therapies by exploring workforce development and new methods of intervention.

Other initiatives developed in this period to support better early identification and intervention

included a £25 million investment from the Department for Education (March 2015) for voluntary

and community sector grants for organisations that work with vulnerable children and young people.

As part of this, nearly £400,000 was allocated to Mind to develop a pilot promoting positive mental

health in schools and £440,000 was allocated to the Anna Freud Centre to create a directory of

mental health services to provide an authoritative source of mental health information for schools.

Similarly, in March 2015, the Government published a blueprint for school counselling services,

which provided schools with evidence-based advice on how to deliver school-based counselling.

Slightly later, in January 2017, the Prime Minister announced a set of mental health reforms that

included mental health first aid training for teachers in secondary schools. This received £200,000 in

Government funding for its first year and was intended to reach every school by 2019/20.

The government green paper in December 2017 brought together many of these school initiatives

and can be viewed as the biggest policy to address schools’ role in supporting mental health of its

children and young people. Its three guiding principles were:

- To incentivise and support all schools and colleges to identify and train a designated senior

lead for mental health

- To fund new Mental Health Support Teams, supervised by NHS Children and Young People

Mental Health staff

- Pilot a four-week waiting time standard for access to specialist NHS CAMHS

In July 2017, the Government committed to taking forward all proposals in the Green Paper, which

were trialled in trailblazer areas, funded by CCGs. By December 2018, Mental Health Support Teams

were set up in 25 trailblazer areas, including 12 areas that were also tested for the 4-week waiting

standard. A further 57 sites were confirmed in July 2019 to start developing 123 Mental Health

Support Teams in 2020. As part of the Government’s response to the Green Paper, a programme

was developed where NHS England and NHS Improvement would support the Mental Health

Services, Schools and Colleges Link Programme seeking to bring together education and mental

health services under CCGs. The Link Programme involved £9.3 million funding from the DfE and was

led by the Anna Freud Centre for Children and Families. It included a series of training workshops to

pool schools’ and settings’ understanding and resources, to draw up long term plans for support,

coordinated by CCGs.

In parallel with this broader focus on schools and universal services, there has been significant

investment in specialist services too. The biggest investment into children and young people’s

mental health provision was Future in Mind in March 2015, led by the Department of Health and

NHS England. The report sets out their five-year plan for improving care, particularly how to make

better links between schools and specialist services. Key aspects included tackling the stigma of

mental illness, improving waiting time standards, and improving access for children and young

people who are particularly vulnerable. There were multiple funding schemes released as part of this

programme. The biggest element of the programme was £1 billion provided to enable new access

standards for CAMHS. Other elements of the programme included £118 million by 2018-19 invested

to roll out Children and Young People’s Improving Access to Psychological Therapies (IAPT), £1.5

million provided by the DfE to pilot joint training for designated leads in CAMHS and schools to

improve links in to services, and £75 million allocated to CCGs to work with local partners to develop

local transformation plans across the full spectrum of need.

Building on this, in February 2016, a series of recommendations were published in The Five-Year

Forward View for Mental Health: A report from the independent Mental Health Taskforce to the NHS

in England. The Mental Health taskforce was launched by NHS England and independently chaired by

the Chief Executive of Mind. The report identified a series of priorities to be addressed (for example,

waiting times and in-borough support for acute inpatient care) and called for investment of £1

billion by 2020/21 to implement these changes. It also called for the Future in Mind

recommendations to be implemented in full. As a result, in July 2016, NHS England published

Implementing the Five-Year Forward View for Mental Health and invested £149 million in CCGs to

fund improvements in CAMHS. In addition, in September 2016, NHS England sought to ‘reprioritise

spending’ to free up £25 million to go to CCGs to spend on CAMHS.

The NHS restated its commitment to The Five-Year Forward View for Mental Health in their NHS

Long Term Plan published in January 2019. The key focus for children and young people’s mental

health services was improving access and, as laid out in the Implementation Framework (June 2019),

this will be funded through a mix of CCG baseline allocations and transformation funding available

over the next five-year period.

However, though additional investment and a greater sense of distributed responsibility across

services is welcome, there is evidence to suggest that funds are not being used consistently to

increase capacity and that many of the policies are not ambitious enough in addressing the real

challenges in the system.

In October 2018, the National Audit Office (NAO) published a report Improving children and young

people’s mental health services looking into whether sufficient progress was being made towards the

targets set in Future in Mind. The report concluded that even if all targets from the NHS’s Forward

View were to be met, “there would remain significant unmet need for mental health services.” The

NAO also argues that the Green Paper does not go far enough, nor does it outline explicit objectives

on how the ambitions will be costed. This latter point is explored further in relation to spending

accountability – the NAO revealed a lack of clarity on the allocation of additional funding in 2014 and

2015 so that “NHS England…cannot confirm that CCGs spent all of the additional funding on these

services”. This is both due to a lack of clear data collection methods and levers for the NHS England

to ensure CCGs increase spending in line with their plans.

Equally, multiple Select Committee inquiries into children and young people’s mental health

expressed concerns around lack of progress made towards government strategies to improve

provision. The Health Committee inquiry on CAMHS in 2014 queried the lack of investment in

children and young people’s mental health as a proportion of the entire mental health budget. It

reported key concerns around access to inpatient services, waiting times, high referral thresholds

and CCGs reporting that their budgets were frozen or cut. In 2017, the Joint Education and Health

Committee inquiry on children and young people’s mental health looked into the coordination

between health and education services; early intervention in schools and colleges; and the impact of

budget pressures. Its main concerns were the varying strength of the links forged between schools

and CAMHS in different areas, and in their level of financial support. They recommended committing

sufficient resource to build on the CAMHS link pilot and taking into account a school’s approach to

mental health and wellbeing in Ofsted’s inspections.

The Joint Education, Health and Social Care Committee also published a report on the Government’s

Green Paper on mental health in 2018. In the report, The Government’s Green Paper on mental

health: failing a generation, the Committees raised concerns about the long timeframes whereby

the plans would be rolled out to only “a fifth to a quarter of the country by 2022/23”. It expressed

hesitations about the potential additional pressures placed on education workforces by the

‘Designated Senior Lead for Mental Health role’ that would be absorbed by existing teaching staff.

The Committee also raised the importance of assessing the transition between child and adult

mental health services, as they felt “there are no substantive plans to deal with the transition from

CAMHS to adult mental health services in the Green Paper.”

This summary of recent policy developments, and their antecedents, demonstrates an increasing

appreciation of the different roles partner agencies, beyond specialist services, have to play in

supporting children and young people with mental health needs. There has also been welcome

investment in CAMHS specialist services designed to help address capacity and wait times. However,

there are still big challenges in the system. Investment in CAMHS has not been used consistently and

weaknesses in the accountability system leaves partners unable to trace the impact of Future in

Mind investments in some places. Likewise, the Green Paper and other school-based policies do not

address how partner agencies are meant to interact across the continuum of support, and arguably,

does not go far enough to tackle the severity of the challenges in the system.

The current national context for supporting children and young

people’s mental health The task of developing a clear picture of the current national context in which support for children

and young people’s mental health is delivered is frustrated by the fact that there is no definitive

national dataset which covers referrals, access to support and outcomes for mental health at

different levels of need. The data which is regularly collected nationally typically only relates to

CAMHS or very specialist admissions, with no visibility afforded to the significant activity in

supporting children and young people with lower levels of need. Furthermore, even the information

that is published on CAMHS is more administrative in nature and does not easily enable comparison

of trends over time or between areas. To understand the national picture, therefore, we are

indebted to the Children’s Commissioner who has used her statutory powers to request analyses of

the NHS databases that would not ordinarily be made available to the public. We are also indebted

to organisations such as Young Minds, the Education Policy Institute and the NSPCC – and the

organisations that responded to these requests - for carrying out painstaking Freedom of

Information requests to access data held at local level but not published nationally.

When brought together these disparate sources of information paint a national picture of support

which, in the words of the Children’s Commissioner in 2017, is ‘shockingly poor’.7 Essentially the

story of support for children’s mental health and emotional wellbeing nationally is predominantly

one of rising demand, insufficient and unequal funding and unmet need.

Rising demand for mental health support for children and young people The most authoritative insight into the prevalence of mental health and emotional wellbeing issues

among children and young people is the Mental Health in Children and Young People in England

2017 survey. This is a major survey commissioned by NHS digital and carried out by the National

Centre for Social Research, the Office for National Statistics and Youthinmind. It follows on from

surveys in 1999 and 2004 and provides an insight into trends in diagnosable mental health disorders

for 5 to 15-year olds from 1999 to 2017. It also, first the first time, estimates prevalence of mental

health disorders among 2 to 4-year olds and 16 to 19-year olds.

The data shows that the prevalence of mental health disorders among 5 to 15-year olds has

increased from 9.7 per cent of the population to 11.2 per cent. This represents an increase of 16 per

cent on the 1999 baseline and equates to roughly 100,000 more children and young people

nationally.8 The increase is particularly marked in girls aged 11 to 15 (from 9.6 per cent in 1999 to

13.0 per cent in 2017). Much of the growth is being driven by higher prevalence of emotional

disorders, particularly anxiety disorders:

Source: NHS Digital, 2018, Mental health of children and young people in England, 2017

It is also clear how prevalence of mental disorders increases with age, with a particular spike for girls

between the ages of 17 and 19.

7 Children’s Commissioner, Briefing: Children’s Mental Health Care in England, 2017 8 Based on applying prevalence rates to ONS mid-2018 England population estimates for 5 to 14-year olds.

Source: NHS Digital, 2018, Mental health of children and young people in England, 2017

The evidence provided by the survey that mental health conditions among children and young

people in England has increased, is mirrored by evidence of rising referrals to CAMHS. This is one of

the issues for which it is difficult to collect accurate national data. However, the Education Policy

Institute published a report in October 2018, Access to Children and Young People’s Mental Health

Services 2018, which showed a 26.3 per cent increase in referrals over the last five years, based on

FOI returns from 55 per cent of CAMHS providers nationally. There was some regional variation in

both the rates of referrals and increases: in the North of England referrals increased by 39.4 per cent

compared with the South of England where they increased by 11.4 per cent.

Similarly, FOI requests made by the NSPCC to NHS Trusts found that the number of referrals from

schools to CAMHS increased from 25,140 in 2014-15 to 34,757 in 2017-18 – growth of 38 per cent in

four years.9

Why is demand for mental health support for children and young people rising in England? There is no definitive explanation about why we are witnessing this surge in demand for support for

mental health which is significantly outstripping the basic increase in the population. However, an

analysis of the data alongside the fieldwork that we have undertaken enables us to begin to

construct a plausible narrative which would benefit from further testing and scrutiny. First of all, the

data on the prevalence of diagnosable conditions points to some interesting correlations.10

Poverty

Children and young people were almost twice as likely to have a diagnosable mental health

condition if their parents were in receipt of low-income benefits than those who were not. For two

to four-year olds this correlation was even more marked – those whose parents were in receipt of

welfare benefits were more than three times as likely to have a diagnosable mental health condition

9 https://www.nspcc.org.uk/what-we-do/news-opinion/one-third-increase-in-school-referrals-for-mental-health-treatment/ 10 The following subsections all draw on the prevalence data in NHS Digital, 2018, Mental health of children and young people in England, 2017

as their peers. There is considerable evidence to show that rates of children living in poverty has

increased in recent years. For example, the number of children living in relative low-income

households has increased by 500,000 since 2010/11.11 Increasing levels of deprivation may therefore

be one of the factors contributing to rising demand.

Special Education Needs

Even more marked than the correlation with deprivation, is the association between poorer mental

health and special educational needs. Children and young people with a special educational need

were more than five times as likely to have a diagnosable mental health condition than those

without. It is striking that the number of children with Education Health and Care Plans (which is the

legal document which describes a child or young person's special educational needs, the support

they need, and the outcomes they would like to achieve) has grown in parallel with demand for

mental health support. In England there has been an increase in the number of children with EHCPs

of 47 per cent between 2014/15 and 2018/19.12 In our Isos Partnership reports for the LGA and

London Councils which explore increasing expenditure on SEND, we set out some hypotheses based

on extensive engagement with councils and schools, about why special educational needs are on the

rise in England. These include a number of societal, policy and funding factors some of which might

be directly relevant to the prevalence of mental health conditions such as longer life expectancy for

children surviving with serious complications at birth, the impact of increasing deprivation, and the

rise of specific conditions such as ASD.13 Interestingly, the NHS Digital mental health survey also

shows a 34 per cent increase in pervasive development disorder or ASD between 2004 and 2017

although this still accounts for a very small percentage of all diagnosable mental health conditions.

Parental mental health and family functioning

Another aspect of the data worth highlighting is the strong association between both poor parental

mental health and poor family functioning with higher levels of diagnosable mental health

conditions among children and young people. Children whose parents suffered from poorer mental

health were almost three times as likely to have a mental health condition themselves, compared

with their peers. This correlation was slightly more pronounced for 2 to 4-year olds. Similarly,

children living in a family which was not functioning well were more than twice as likely to have a

mental health disorder than their peers. It is worth noting, in this regard, that at the same time that

demand for mental health support has been rising nationally, so have the number of children subject

to child protection plans and looked after children – an increase of 5 per cent and 12 per cent

respectively over the last five years between 2015 and 2019.14 Anecdotally, local areas point to

several trends such as housing pressures, benefits changes, income instability or job insecurity, rising

levels of school exclusions and diminishing community resources and capacity which may be

contributing to these interlinked vulnerabilities.

Anxiety related conditions

The prevalence data also shows that the prevalence of anxiety disorders in 5 to 15-year olds have

grown by nearly 50 per cent between 2004 and 2017. Those who engaged in our research

highlighted two trends which they felt were contributing to higher levels of anxiety, particularly

11 DWP, Households below average income (HBAI) statistics 12 DfE, Statements of SEN and EHC plans: England 2019 13 Isos Partnership, Have we reached a tipping point? Trends in spending for children and young people with mental health needs in England, 2018, and Under Pressure: An exploration of demand and spending in children’s social care and for children with special educational needs in London, 2019. 14 DfE: Characteristics of children in need: 2018 to 2019; DfE: Children Looked After in England (including adoption) year ending 31 March 2019

among the older age-ranges. The first is the growing impact of social media, both in relation to the

pressure it can place on individuals to feel ‘successful’ and the all-encompassing impact that bullying

on social media can have on a young person’s home and school life. The second is the increasingly

academic nature of the curriculum and the focus on ‘high-stakes’ examinations and accountability

measures which some young people find very challenging.

Why are referrals rising more quickly than prevalence levels? However, the data about diagnosable mental health conditions can only tell us part of the story. The

information available points to levels of referrals rising at a faster rate than the underlying

prevalence. Our fieldwork conducted during this research, and the studies carried out by other

organisations, point to three interlinked issues which may explain why referrals to specialist mental

health services are rising faster than the prevalence of diagnosable mental health conditions.

Firstly, nearly a quarter of children referred to specialist mental health services were rejected in

2017/18. The two most common reasons for a referral being rejected was that children’s mental

health conditions were not serious enough to meet the eligibility criteria for treatment or that the

condition was not suitable for CAMHS intervention.15 This suggests that some of the increase in

referrals is being driven by increasing numbers of children and young people whose needs may not

fit the description of a ‘diagnosable mental health condition’ (and therefore will not therefore be

captured within the prevalence data) but who are nonetheless experiencing a significant degree of

emotional distress.

Secondly, a number of those involved in this research remarked that awareness of mental health as

an issue in general, and children and young people’s mental health in particular, has risen

substantially in recent years and that this has contributed to rising numbers of referrals. Anecdotally,

children, young people or their families are more likely to raise concerns about their mental health

and professionals working in universal services are more likely to recognise some of the signs of poor

mental health. This is partly as a result of deliberate policies by government to increase the profile of

children and young people’s mental health and partly also the result of lobbying by charities, the

Children’s Commissioner and others who have put mental health more obviously at the forefront of

the discourse on children’s wellbeing.

Finally, the rising level of referrals is not just an indicator of increasing levels of need, but also the

collective capacity of the system to cope with those needs. In our work on special educational needs

and rising expenditure on children’s social care, we point to the impact of austerity and the wider

policy and funding landscape on the ability of a range of partners to support the most vulnerable

children and young people without recourse to specialist services.16 Our fieldwork for this research

suggests that the same is true for mental health. As budget cuts have been made to pastoral support

staff in schools, targeted youth services, children’s centres, health visitors and school nurses the

collective capacity for universal services to provide additional support for children and young people

experiencing turbulence in their lives and emotional distress has been diminished. The story of rising

referrals therefore is not just about rising levels of poor mental health and emotional wellbeing

experienced by children and young people. It is also likely to be about the pressures and strains

experience by core universal service provision in a time of austerity.

15Education Policy Institute, Access to children and young people’s mental health services, 2018. 16 Isos Partnership, Have we reached a tipping point? Trends in spending for children and young people with mental health needs in England, 2018; and Under Pressure: An exploration of demand and spending in children’s social care and for children with special educational needs in London, 2019.

Insufficient and unequal funding Many of the local areas that took part in this research described how support for children’s mental

health is delivered in the context of historic and chronic underfunding. Even with the increased

investment seen in recent years, parity of funding between children’s mental health and physical

health remains a long way off, as does closing the gap between children and adults’ funding. In 2018

the Children’s commissioner reported that “on average local areas spend £54 per child on mental

health compared to £800 on physical health” and “currently 15 times as much is spent on adult

mental health as child mental health”.17

Nonetheless, the data on expenditure published by both the Children’s Commissioner and Young

Minds shows that expenditure on children’s mental health services is increasing. Data collected by

Young Minds through a Freedom of Information request shows that CCG expenditure increased from

£254 million to £335 million between 2013-14 and 2017-18 and council expenditure increased from

£56 million to £69 million representing an increase of 31 per cent and 22 per cent respectively over

the five-year period.18 This data is based on 111 CCGs and 62 councils which provided data across all

five years. The total 2017-18 national CCG spend on children’s mental health reported by the

Children’s Commissioner was £641 million plus a further £47 million for eating disorders.19

The Children’s Commissioner carried out an analysis of expenditure on lower-level mental health

services, based on a Statutory Information request which was completed by all local authorities with

responsibilities for children’s services and public health and almost all CCGs. This found that total

expenditure on lower-level mental health services rose from £181 million in 2016/17 to £217 million

in 2018/19.20

The rate of expenditure on children’s mental health has been increasing more quickly than the

underlying population, therefore expenditure per capita has also increased. The Children’s

17 Children’s Commissioner, Children’s Mental Health Briefing, A briefing by the Office of the Children’s Commissioner in England, November 2018 18 Young Minds, Children’s Mental Health Funding, where is it going? 2018 19 Children’s Commissioner, Children’s Mental Health Briefing, A briefing by the Office of the Children’s Commissioner in England, November 2018 20 Children’s Commissioner, Early Access to Mental Health support, 2019

commissioner, for example, reports that spend per capita has increased from £49 to £54 between

2016/17 and 2017/18.

However, the data also shows very significant local variations in expenditure:

• Between 2016/17 and 2017/18, 66 per cent of CCGs increased or maintained their

expenditure on children’s mental health but 34 per cent decreased their expenditure

(source: Children’s Commissioner).

• 43 per cent of CCGs had increased their spending by less than the additional funding

invested through Future in Mind (source: Young Minds).

• The range in CCG expenditure on CAMHS services extends from £162 per capita in the

highest spending area to £9 per capita in the lowest spending (source: Children’s

Commissioner).

• The range in expenditure on lower level mental health services extends from £173 per capita

in the highest spending area to £0.26 per capita in the lowest spend (source: Children’s

Commissioner).

However, all these figures need to be treated with a degree of caution as there are significant

discrepancies in how individual areas report their data. There are several factors which contribute to

the financial complexity:

• Total expenditure on children’s mental health is made up of many different funding sources.

For example, one fieldwork area that we visited as part of this research listed 10 distinct

funding streams in their CAMHS transformation plan.

• CCGs and councils are not coterminous which can make it difficult to apportion spend, for

example in a council area which covers multiple CCGs or vice-versa.

• A proportion of the funding and expenditure on children’s mental health is ‘hidden’. For

example, there is no straightforward way of collating how much money individual schools

spend on school counselling services from their own budgets. Similarly, it is difficult to put a

financial figure on the percentage of a youth worker’s time which might be spend informally

support the mental health of the young people they engage.

As part of our fieldwork, we asked participating local partnerships to share with us some of their

most recent (2018-19) financial data on expenditure on children’s mental health. We received

returns from four local areas. As with the national data, it is important to treat this information with

a degree of caution as different areas count different budget lines within the overall envelope of

‘children’s mental health’. The data they shared indicates that in these local areas on average

around 77 per cent of funding for children’s mental health is provided by CCGs and about 71 per

cent is allocated to CAMHS services. In comparison, in her 2019 report, Early Access to Mental

Health Support, the Children’s Commissioner identified that just over half the funding for lower level

mental health services came from local authorities. The difference arises because the Children’s

Commissioner was focussing on expenditure on non-specialist preventative or early intervention

services, whereas the finance data reported by our fieldwork areas captured all mental health

expenditure by local areas including specialist CAMHS.

We also asked fieldwork areas to estimate the average split in funding between support for universal

provision, targeted provision and specialist provision and the five THRIVE categories. This shows that

the majority of expenditure is directed towards targeted services and the largest category of

expenditure within the THRIVE framework was ‘getting help’. However, there were big differences

between local areas in their allocation of support to individual tiers or quadrants. For example, in

one area 56 per cent of expenditure was allocated to ‘universal support’ compared with 2 per cent in

another area. Similarly, the range in local areas reported spend on ‘getting help’ within the THRIVE

framework extended from 13 per cent of their total expenditure in one council to 72 per cent in

another.

The finance data local areas shared with us also confirmed the trend nationally of considerable

variation in per capita spend between areas. We calculated per capita (0-19) spend across the

totality of funding for children’s mental health within a local authority area (CCG, LA, Public Health,

central government grants and other funding). We found that the lowest spending of the four

authorities spent in total £59 per head and the highest £150 per head. The average was £78 per

head. Although these figures are not directly comparable with the per capita data reproduced above

(these are based on total spending, those above are based on either CCG or lower-level spending)

nonetheless it is interesting to note that the range appears to be somewhat smaller than the

national range, due to a higher minimum per capita spend. This suggests that the fieldwork

authorities might be comparatively higher spending on mental health than other authorities

nationally. There are, of course, a very wide range of factors which may influence levels of spend in

any locality and there is no indication that there is an ‘ideal’ level of expenditure on children and

young people’s mental health.

Unmet need Despite the very substantial additional investment made in children and young people’s mental

health in recent years, the capacity in the system has not kept pace with rising demand. The result is

too many children and young people with significant mental health difficulties failing to meet the

threshold for treatment or intervention and those who do meet the threshold too often

experiencing very long waiting times for treatment.

The NHS 2019 CAMHS benchmarking report stated “Within community CAMHS, there has been a

clear upward trend in referrals to CAMHS over the last seven years, and numbers of referrals

accepted have largely mirrored the increases in demand. However, although increased capacity has

been demonstrated, demand continues to outstrip supply with increases in young people on waiting

lists to access CAMHS and waiting times longer than the previous year.”

Data collected by the Children’s Commissioner on children and young people accessing CAMHS

activity in 2017/18 is the most recent comprehensive national study that has been produced.21 This

showed that 324,724 children and young people accessed NHS CAMHS during the year. This

represents just 2.85 per cent of the total population of England – much lower than the NHS digital

survey-based prevalence rate of 12.8 per cent. Indeed, based on ONS mid-2018 England population

estimates, a prevalence rate of 12.8 per cent of 5 to 19-year olds would equate to roughly 1.27

million children and young people.

Of those who were referred to CAMHS during 2017/18, 37 per cent had their referral closed before

they entered treatment. There are several reasons why this might occur, but the most common is

that the child or young person did not meet the threshold for accessing services. Of the children who

were both referred and treated during 2017/18, just over half entered treatment within six weeks

and a large majority of those were seen within four weeks. However, nearly a quarter waited more

than 12 weeks for treatment and the average waiting time for those who did enter treatment was

just under two months. Almost a third of those referred to CAMHS in 2017/18 were still waiting for

treatment at the end of the year.22

All this points to very significant numbers of children and young people with mental health needs

either never receiving a referral, not meeting the threshold for services, or waiting for three months

or more before accessing treatment. It is of particular concern that nationally no data is collected

which shows what happened to children who received a referral but did not meet the threshold for

CAMHS or the substantial number of children and young people who are never referred to CAMHS

but may (or may not) be receiving very effective earlier or lower level support from other partners in

21 Children’s Commissioner, Children’s Mental Health Briefing, A briefing by the Office of the Children’s Commissioner in England, November 2018 22 Children’s Commissioner, Children’s Mental Health Briefing, A briefing by the Office of the Children’s Commissioner in England, November 2018

the system. This data is simply not collected nationally, which creates a very real blind spot in

assessing the efficacy or sufficiency of the system in supporting children and young people’s mental

health.

Beyond funding – systemic challenges to delivering effective support The evidence set out above clearly demonstrates how rising levels of need combined with funding

that continues, despite significant investment, to be insufficient leads to too many children and

young people not receiving the support that they require in a timely way. However, evidence

collected from councils and their partners through this research suggest that there are several

systemic challenges which get in the way of using the resources available as effectively as possible

and delivering the best outcomes for children and young people. Here we summarise some of the

key issues raised by participants in the workshops and during the fieldwork stage:

System complexity and fragmentation Historic underfunding of the system is compounded by the complexity of budgets, commissioning

cycles, and discrete initiatives which make it more challenging to achieve a clear strategic overview

and the most efficient use of resources. Those who attended the workshops described how the lack

of a joined up vision from central government, with different priorities being set by the NHS, the

Department of Health and Social Care, the Department of Education and Public Health England has

created a situation on the ground in which it was too easy for partners to retreat behind their own

organisation’s objectives and not consider the totality of resource and capacity that could be

deployed in the local area. This also meant that accounting for how funding for mental health was

being spent, avoiding duplication and securing partners’ buy-in to medium and long-term spending

commitments could be very difficult.

Contributing to the sense of complexity and fragmentation, was the sheer number of pilots and

separate ring-fenced grants which have proliferated in this policy area in recent years. Local

partnerships reported that although the additional funding was welcome the short-term nature of

the pilots, the fact that they were not always joined up or clear in what they were testing, and the

lack of flexibility for local areas to adapt them to their delivery context created a further barrier to

sensible and strategic long-term planning.

Capacity and wellbeing of mental health professionals A clear message from many of the local areas attending the workshops was that there was not

sufficient workforce capacity to manage the increasing demand for mental health support. This was,

in turn, creating issues for the wellbeing of the workforce who were experiencing high levels of

stress in an environment in which they could not meet the needs of children and young people to

the extent that they would wish. There are well documented staff shortages in child psychology and

psychiatry, including education psychologists and CAMHS practitioners, as well as associated

professional disciplines such as children’s social work. When staff shortages becoming acute it

becomes even more difficult to retain existing staff because workloads and pressure rise, thereby

creating a vicious circle.

A number of local areas also commented that, as a corollary of the system fragmentation described

above, it could be challenging to make the most of the professional workforce capacity that was

available. For example, despite the significant impact that both professions can have on the mental

health and emotional wellbeing of children and young people, in many areas educational

psychologists and CAMHS practitioners seldom train to together, work together or plan together for

how they will support individual children and young people. The two professions are too often

separated by different terminology, different strategic goals, different administrative processes,

different funding routes, different professional pathways and different leadership. This does not

support the most efficient or effective use of scarce and valuable resources.

Issues of staff capacity and wellbeing do not only manifest among mental health professionals. A

number of areas also described how shortages and workload pressures on professionals in the key

universal services – schools, school nursing and health visiting – were hampering their ability to play

a greater role in the support of children and young people’s mental health, both in terms of the

direct time to support individual young people or the indirect time to undertake the professional

development needed to develop enhanced skills in these areas.

Not enough investment in or focus on effective early intervention The importance of intervening early in children’s mental health, to build secure relationships and

emotional resilience, and prevent issues from escalating is well recognised. And yet, the funding,

incentives and targets within the system remain geared to address unmet need at the specialist end

of service delivery rather than boldly redirecting the focus of activity to earlier intervention.

The Children’s Commissioner found that in 2015-16, 38 per cent of NHS spending on children’s

mental health went on providing in-patient mental-health care which was accessed by 0.001 per

cent of children aged 5-17; 46 per cent of NHS spending went on providing CAMHS community

services, which were accessed by just 2.6 per cent of children aged 5-17. However, “only 16 per cent

of NHS spending goes on providing universal services. This needs to support the one in ten children

who are thought to have a clinically significant mental health condition but are not accessing

CAMHS. It also needs to support a – currently unknown – number of children with lower level needs,

who would be less likely to develop a more serious mental health condition if they were provided with

timely support.” The Children’s Commissioner also cites evidence provided by the Department of

Health on the cost effectiveness of earlier intervention. They estimated that a therapeutic

programme delivered in a school costs less than £250 but delivers a lifetime benefit of more than

£7,250 pounds.23

Nor is it simply a question of money. As noted above, the paucity of data about children and young

people accessing lower-level mental health support, or the outcomes they achieve, is striking; the

responsibilities for providing and overseeing earlier intervention in mental health are unclear; the

understanding of what good looks like in terms of universal provision for mental health has not been

defined; and the system is incentivised to strive for targets that relate to access to specialist support

and not long-term outcomes.

How local partnerships are overcoming these challenges Despite the very real challenges outlined above that beset the delivery of support for children and

young people’s mental health in England, our fieldwork visits to eight contrasting local areas showed

just how much could be done, through highly effective partnership working, to mitigate some of

these challenges at the local level.

Throughout our fieldwork engagements nine key themes, or enablers, recurred as critical elements

in establishing an effective partnership-based approach to supporting children and young people’s

mental health. Where these were securely in place, local areas felt that they were able to deliver

better and more timely access to support, earlier intervention and prevention and more efficient use

of resources. These nine key enablers are all mutually interdependent and reinforcing. In particular,

23 Children’s Commissioner, Briefing: Children’s Mental Health Care in England, 2017

it is helpful to think of them as three sub-groups comprising three enablers in each, which contribute

to three overarching ways of working:

1. Making children and young people’s mental health and wellbeing a shared priority;

2. Focusing on and investing in earlier intervention and prevention; and

3. Delivering specialist support differently

This relationship between the nine key enablers and the three ways of working is illustrated in the

graphic below:

In the following sections we describe each of the nine key enablers in turn and illustrate them with

examples from our eight fieldwork areas. These are, we believe, the critical building blocks to

creating a dynamic, outcomes-focused partnership that has the capacity to support more children

and young people to achieve good mental health and emotional wellbeing. What we observed in the

operation of these local partnerships was not a segmented approach to delivery in which CAMHS

focused exclusively on specialist support for those with more complex needs and local government

and its partners in universal services attended to earlier intervention. Instead what we saw was a

more nuanced and dynamic way of working in which professionals from a range of disciplines and

sectors might collaborate in the delivery of support from the universal all the way up to the most

complex.

Keeping children’s mental health high on the agenda when there are numerous competing priorities

for time and resources requires commitment. Managing to forge a genuinely collaborative

partnership around children’s mental health at a time when countervailing pressures are causing

joined-up ways of working to fragment similarly requires concerted will and discipline. Those areas

which were making children and young people’s mental health a shared priority were doing so

through strong political and professional leadership; establishing ways of working in partnership that

were self-reflective and trusting; and integrating commissioning and needs assessment to ensure the

most efficient use of the total resources.

Leadership and vision Unsurprisingly, at a time when children and young people’s mental health and wellbeing has too

often lacked the attention and prioritisation it deserves, clarity of vision and strong leadership are

essential prerequisites. In local government this starts with the commitment of elected members to

promoting children and young people’s mental health. Firstly, during a period in which every council

has to make difficult decisions about spending, the importance of elected members being prepared

to advocate for the continued, or increased, investment of local government resources in

programmes and services to support children’s mental health cannot be underestimated. However,

the role of elected members goes much further than just protecting expenditure. It is also about

promoting a vision and acting as an advocate.

Many of the members to whom we spoke described how improving children’s and young people’s

mental health was integral to their vision for their community as whole, be that in terms of health,

resilience, learning or employment. They also felt they had an important role as advocates for

children’s mental health with other council members, residents and employers. They described how,

as an issue, children’s mental health was not always well understood among their constituents and

that they, therefore, could have a significant positive impact in highlighting some of the issues that

young people are facing and the ongoing costs to both the individual and society of poor mental

health.

In Liverpool, leaders had a vision to bring mental health and wellbeing support out into the

community, in order to identify mental health needs early; to reach a broader set of young people;

and to create awareness of the possible challenges that young people can encounter that might

affect their mental health. The partnership therefore commissioned YPAS, a registered charity, to

deliver joined-up mental health support through three community hubs. The buildings were

previously local authority owned assets that were repurposed as a venue for the mental health hubs.

As such, the introduction of the hubs met with some opposition from residents who were anxious

about the loss of community spaces and about the specific role of professionals working in the hubs.

Councillors were pivotal in working with the community and ran consultation events to identify their

concerns and develop practical solutions. It was only through close liaison and respectful listening to

the community that these tensions were revealed and resolved. The YPAS Hubs have now become a

non-confrontational and easily accessible space for children and families to seek trained and

specialist support. The types of services offered out of the YPAS Hubs include counselling, drop-ins,

information and guidance from non-therapeutic, qualified youth workers, fortnightly GP Champions,

parental support coffee mornings and more specialist services (such as transgender support groups,

Domestic Abuse Service and Talent Match programme to mentor NEET pupils). One colleague

commented on how embedded the hub now is in the community in saying, “If you go to the centre

and professionals were not wearing lanyards, it would be difficult to know the difference between

professionals and parents – there is a clear sense of mutual ownership of the space”.

Where elected members create a political environment in which children and young people’s mental

health is championed, there is an equally important role for senior officers within children’s services

and senior leaders within the CCG to create the operational environment in which partnership

working for children’s mental health can flourish.

One Director of Children’s Services, for example, argued that in an environment of austerity – in

which all councils and their partners are now operating – strategic leaders face a choice between

retrenchment to protect their own budgets or more ambitious collaboration to try to get maximum

impact from the combined resources available. They also face a choice between focusing on

statutory services and trying to ration access to the highest cost support or focusing heavily on early

intervention and prevention to address needs at the very earliest opportunity.

Senior leaders described the importance of locating children and young people’s mental health

within an overarching programme and a clear set of objectives for the whole council, for example

creating resilient families or living healthily. They also emphasised the importance of creating the

conditions for mental health not treating mental illness. This relied upon setting clear expectations

for staff across disciplines to work together, to be creative and to learn from each other. One

Director of Children’s services described this as the “authorising environment” for excellent practice.

In practical terms, the leadership vision in the areas we visited was normally distilled into a single

shared transformation plan for children’s mental health which encompassed children’s services,

schools, public health, the CCG, CAMHS, VCS and other key providers. This was underpinned by a

strong needs analysis which quantified the progress that the partnership was seeking to achieve.

All the fieldwork areas that we engaged with had adopted the THRIVE framework which was jointly

developed by The Anna Freud Centre and Tavistock and Portman NHS Foundation Trust. The THRIVE

framework is an integrated, person centred, and needs led approach to delivering mental health

services for children, young people and their families. It conceptualises need in five categories;

Thriving, Getting Advice and Signposting, Getting Help, Getting More Help and Getting Risk Support.

THRIVE emphasises that the decision on how best to support a child’s mental health cannot be

based purely on their diagnosis or presenting symptoms. It stresses the importance of drawing on

the evidence base, alongside being transparent about the limitations of treatment, and explicitly

engaging children and their families in shared decision-making about the type of help or support

they need. The framework suggests that all those involved in the delivery of care across health,

education, social care and the voluntary sector work closely with one another to meet these needs,

agree on aims, and review progress. In the local areas we visited, the THRIVE framework was proving

a powerful vehicle for bringing partners together with a shared strategic vision and a common

language for how they would achieve that vision. We were struck by the way in which the process of

adopting this model, and use of the self-assessment tool, helped to facilitate positive change both in

terms of staff development and closer working practice.

Self-reflective partnership Having a robust governance structure in place to oversee the shared vision and monitor delivery

against the strategic plan was a critical element in the success experienced by many of the fieldwork

areas. During our visits we saw evidence of a wide range of partners, both commissioners and

providers, coming together regularly to report on progress, collectively problem solve, and shape the

future delivery priorities. Where these were working most effectively, partnership-based governance

structures for children’s mental health:

• brought a really diverse set of partners to the table, with strong representation from the

voluntary and community sector;

• showed evidence of knowing each other’s services, strengths and challenges and being

familiar with working together in order to solve problems and support each other;

• were united in seeking out ways of working that would improve outcomes for children and

young people;

• made time to think about what had worked, and what had not worked, and used this

knowledge to plan their future delivery priorities.

• had meaningful, vibrant conversations about how to improve rather than going through the

motions of performance reporting.

When asked what made their partnership structure work well, participants in one fieldwork area

replied: “we can trust that actions will be delivered”; “there are active individuals in the system”;

and “everyone wants the best outcomes”. The emphasis was very much on building trust and

confidence by acting in ways that delivered on the partnership’s priorities.

Underpinning these partnerships many local areas had thought carefully about what metrics they

would measure and why. Being able to reflect on the quality and impact of provision required not

only forensic tracking of key outputs, such as the number of children and young people accessing

support or the waiting times from referral to treatment, but also wider thinking about how to

measure outcomes and changes in children and young people’s lives. For example, Salford THRIVE

partnership had commissioned a Resilience Survey that was completed by children in year 4, year 8

and year 12 and provided each school, and the local area as a whole, with an average ‘resilience

score’ based on children’s answers to questions designed to assess their overall emotional wellbeing

and resilience. The partnership aims to use this as a baseline for measuring progress and impact

each year.

In many cases the mental health and emotional wellbeing partnerships reported into the Health and

Wellbeing Board. In one area the Director of Public health described how the health and wellbeing

board had both a children’s group and a transitions group both of which saw improving mental

health as a key priority. She felt that the quality of the underpinning needs assessment was an

important lever in achieving that high-level commitment.

Integrated commissioning A shared vision, committed leadership and a self-reflective partnership structure found expression in

an integrated approach to commissioning children’s mental health support in many of the areas we

visited. In practical terms some of the local areas had appointed joint commissioners across the

council and the CCG so that there was single oversight of all commissioning for children’s mental

health and wellbeing. Other areas had not gone down the route of structural staffing changes but

had put in place day to day ways of working that meant the CCG lead commissioner and the council

lead commissioner for mental health collaborated closely and effectively took joint decisions. In a

minority of fieldwork areas, integrated commissioning between the CCG and the council was not as

far advanced. In these areas the council had forged a very strong relationship with the CAMHS

provider to ensure joined up planning and integrated service delivery.

Pooled council and CCG budgets, under a section 75 agreement, were a powerful tool for joined-up

planning, investment and delivery, in some of the fieldwork areas. One DCS described their

longstanding pooled budget as “an enabling contract. It allows each partner to spend and discharge

the responsibilities of the other partner, but you need the right culture in place. It gives continuity to

a set of ideas and assists people to make braver decisions if the risks are safely managed”. Several

areas were looking to move towards a pooled budget agreement in the near term, as a result of

ever-closer collaboration around commissioning priorities and spending decisions. In times of

austerity and pressure on budgets, a formal pooling agreement was seen as extra insurance against

one partner unilaterally deciding to reduce investment in joint commitments. It was also seen as a

way to ‘hard wire’ in the relationships and ways of working that take years to develop and future

proof these against changes of personnel.

Integrated commissioning, however, is not important as an end in itself, but because it enables

bolder decisions to be made about how money is spent and creates the conditions in which the total

investment in children’s mental health is maximised. In one local area a provider described the

‘bravery’ of the approach to integrated commissioning which enabled providers and commissioners

to look at a problem together and co-create a solution. For example, as a result of rapidly increasing

access both VCS and NHS providers were experiencing rises in waiting times. The partnership

therefore looked at how the system could be redesigned to alleviate pressure, and allocated funding

so that additional resource could be put into specific pinch points as a well as increasing support in

schools to enable more needs to be met without recourse to a referral to specialist services. In

another area they described how “providers and commissioners are part of a partnership” which

meant they could challenge each other from a position of mutual respect and trust. The CCG offered

a lot of capacity building for the VCS organisations it commissions, for example in IT systems,

governance structures, and the building of a workforce for evidence-based interventions. The

commissioning partnership has also thought carefully about how to demonstrate the impact of

services, paying attention to both quantitative and qualitative measures of success.

Local areas also reflected on how integrated commissioning arrangements had challenged them to

look differently at how things had been done historically. One area, for example, described how its

block CAMHS contract was based on numbers of children seen and treated in a clinical setting, but

did not remunerate the provider for providing advice, guidance and training to professionals in other

settings such as schools, youth services or children’s centres. As this was becoming an increasingly

important means of securing effective earlier intervention, work was beginning to unpick the historic

block contract and put it on a footing which significantly incentivised early intervention and

prevention.

In Salford, funding for children’s mental health had historically been split between the council and

the CCG. The council had traditionally funded early intervention CAMHS work, Youth Justice mental

health support and Emerge (a CAMHS service for 16 to 17-year olds). The rest was funded by the

CCG, based on an activities contract with the CAMHS providers of £3.2 million with some additional

specialist services. In 2018, the decision was made to test integrated commissioning within CAMHS,

and in 2019 Salford implemented a pooled budget arrangement between the CCG and the council

for all age health and care. This was motivated by the ambition to move away from discrete

contracts so that budgets could be used more freely once pooled. The process to move to integrated

commissioning required close working with care, education, and health to build their understanding

of the benefits. As part of this, an integrated commissioning post was developed across the CCG and

the local authority to create further strategic join up and oversight. Partners also worked together to

articulate a shared vision on aligning commissioning and budgets, underpinned by a needs analysis

of the local area. By jointly developing the vision, there was broad understanding across partners of

how joint commissioning would work and they largely felt bought into the process. This vision was

also matched by a governance framework developed to build a sense of shared responsibility, rather

than a culture of shifting risk and blame. Colleagues were keen to stress that integrated

commissioning was only made possible by partners building and owning a vision together, sharing

the risk and being “brave” when it came to commissioning, in order to address problems creatively.

Shifting the focus of the system towards earlier intervention and more effective prevention can bear

significant dividends, both in terms of the long-term emotional wellbeing of children and young

people and the most efficient use of resources. The fieldwork areas described three key enablers

which were helping them to direct capacity and attention towards earlier intervention. These were

meaningful engagement with children and young people; capitalising on opportunities within the

community to promote good mental health for everyone; and developing a children’s workforce

with skills and aptitudes needed to support mental health through their daily interactions with

children and young people.

Working with children and young people ‘Only when we truly listen to our children and young people - and value what they say- will we start

to make the decisions that have a positive impact’ was the very clear message that came from one

assistant director engaged in the fieldwork. Local areas had used a range of different mechanisms to

work carefully and deliberately with children and young people to develop services which met their

needs. These included large-scale consultation events, appointing young commissioners to guide

service design and funding decisions, young people contributing to interviews for key posts, and

using youth councils to help shape priorities for children and young people’s mental health and

promote those with schools and other partners. Engaging children and young people in designing

and evaluating services tended to be most successful when it permeated each level of the system,

from service user feedback up to shaping whole-system priorities, and when it was part and parcel

of how partners worked together, rather than a one-off exercise.

Local areas were also doing more to understand the lived experience of children and young people

with poor emotional wellbeing and mental health. In Hertfordshire, for example, the Director of

Public Health is working on a public health approach to exam stress and working with children and

young people in ten schools across the county to understand in more detail the issues that cause

extreme anxiety, including stress around achieving and coping with parental pressure. This is

important given the data that suggests emotional and anxiety related disorders are among the

fastest growing nationally. In Dorset, the lead member described the transformational effect on

policy that arose from inviting young people who had been excluded from school to describe their

experience to councillors.

Many local areas described how young people had strongly expressed a preference for support that

was non-stigmatising, accessible and based in community settings. There were good examples of

how councils and their partners had redesigned aspects of their support offer in response to these

messages. For example, in Salford, they had commissioned a third sector organisation to work with

35 LGBTQ young people to understand the mental health issues that they faced and to co-design a

service that would meet their needs. Specific outcomes from this engagement included rolling out

training on gender identity for professionals working with children, young people and families,

creating LGBT friendly GP practices and pharmacies, and developing safe places in the community

where LGBT young people can meet and interact. An LGBTQ+ working group continues to oversee

this work and includes LBGT young people representatives.

In Camden the tragic suicide in 2012 of a young man aged 18 waiting for support from adult mental

health services prompted the partnership to completely redesign their offer for 16 to 25-year olds.

They started with a survey of 500 young people which identified high levels of unmet need. Young

people told commissioners that services at 18 fell apart; that they wanted more joined-up services

available through self-referral and open access. They wanted support in place for young people not

meeting thresholds and those not engaging with clinical interventions and treatment.

Through careful, iterative engagement with a group of young people they developed the concept of

The Hive – a community based youth hub that provides social activities, a safe place to spend time

and meet friends, access to employment support through social entrepreneurship, and a one-stop

shop for mental health, sexual health, and physical health. A Youth Board is central to running the

centre and young people own the space, doing tours to welcome those who visit or attend for the

first time.

The heart of The Hive is about social interaction – a place where young people can make friends with

each other and develop trusting relationships with adults. This is based around a range of free

activities designed by the young people – cooking, yoga, guitar lessons. But it is also a place where

access to a mental health professional is available seven days a week, without a formal referral. An

evaluation of The Hive carried out by The New Economic Foundation showed the return on

investment to be £3.40 for every £1.00.

A number of local areas which took part in the research also pointed to the preference young people

had expressed for accessing support for mental health online. Many fieldwork authorities had

subscribed to Kooth – an online platform that provides access to counsellors and the Kooth

community from 12pm to 10pm weekdays, and from 6pm to 10pm on weekends. Bedford was one

of the local areas that had recently signed up to Kooth and was extremely positive about the number

of young people accessing the service from communities that had previously been reluctant to

engage with traditional mental health services, particularly ethnic minority young people.

Finally, local areas were not just engaging young people more meaningfully in the design of services

but also skilling them up to provide support and advice to their peers. One VCS organisation with

whom we met described how they had carried out a survey of 1,200 young people and asked them

where they would go if they were worried – 60 per cent said that they would first go to another

young person for advice. This prompted a significant programme of skilling up young people as peer

mentors and peer educators, and developing groups led by young people for young people on issues

such as self-harm.

Weymouth College in Dorset provides training in emotional health and resilience for young people

who want to become peer mentors. Students who are targeted are those whose own emotional

wellbeing is an issue. They have to carry out a piece of work which involves research and a full level

2 qualification. They then build on and use this work and have the opportunity to become a peer

mentor. One young person whose resilience was very low at the beginning, really excelled on the

programme and presented to a large conference. It has been so successful that there are now 126

peer mentors. A student will come to a ‘tea and toast session’ where they do presentations to each

other and talk about their journey, with many building a friendship group during the process. The

programme is currently targeted for those who are at risk of NEET or are struggling with low grades.

Promoting good mental health Central to the concept of earlier support and prevention in mental health is switching the focus from

treatment of mental health conditions to laying the foundations for good mental health and positive

emotional wellbeing. Many of the local areas we visited were in the process of making this

transition.

There is very substantial evidence that the early years of a child’s life are critical for forming the

strong attachments that create the platform for good mental health later in their lives. Many of the

local areas we visited had recently reshaped their children’s centre, perinatal and early years offer to

significantly increase the focus on supporting parents and professionals to understand young

children’s emotional and mental development and implement proven strategies for promoting

ongoing good mental health. For example:

• In Camden, children’s centres are a one-stop-shop for perinatal and infant mental

health, with health visitors co-located with family workers and strong links to midwifery

services. Through the children’s centres, they offer parents taking up the two year-old

free entitlement the opportunity to take part in parenting programmes encompassing

attachment and good parental mental health.

• Hertfordshire have recommissioned their children’s centres and Public Health Nursing

(Health Visiting and School Nursing) functions, bringing them together to create the

‘Family Centre Service”. The Family Centre Service supports families, from the antenatal

period, with an integrated offer of support. All staff in the family centres have a clear

mental health component to their work including training on attachment and brain

development.

• Dorset have run “Incredible Beginnings” training for nurseries to help staff to

understand young children’s behaviour and how to respond in ways that enable children

to effectively regulate their emotions. It is starting to change the culture in nurseries,

with a strong network in place of those who have benefitted from the training.

• On the Isles of Scilly their vision is to build emotional resilience from conception up.

They are funding all two-year olds for 10 hours nursery provision; running early years

sessions with the health visitor and school nurse to identify issues early; and delivering

training on reducing parental conflict.

• In Salford, trauma informed practice runs through their peri-natal offer. Health visitors

carry out a screening check for attachment issues at eight weeks and use screening tools

at core contacts to assess parental mental health. The Early Help service run five to

thrive training (an attachment-based training programme for parents) through their

children’s centres and CCG funds home start, through a bank of 59 volunteers to

provided targeted support to new mothers. Innovation funding has been secured to

extend this offer to fathers from April 2020.

Building on the platform created at early years, all the local areas we engaged with had worked with

their schools to embed positive ways of promoting mental health within the curriculum, within

pedagogy, and within approaches to behaviour management. For example, Hertfordshire had

developed a kite mark scheme to recognise schools which had adopted a whole school approach to

promoting good mental health and Salford had developed an accreditation programme for

emotionally friendly schools and settings which are trauma-informed and attachment aware. They

feel that this has begun to change the language in schools around behaviour.

In Dorset there has been a specific focus on support to teachers to improve children’s emotional

wellbeing and behaviour in a systematic way. ‘I can problem solve’ is an evidence based early

intervention programme developed in the USA. Educational psychologists have been overseeing the

successful implementation of this programme, including training staff and ongoing support for

trainers. It aims to help children be aware of feelings and motives and generate a variety of solutions

to problems. It is being implemented with early years and primary teaching staff. The results of the

evaluation carried out so far have been very promising including lowering of impulsivity, with

children learning to stop and think, a positive impact on Strength and Difficulty Questionnaire scores

and language development, with a particular increase in emotional vocabulary.

Some of the local areas were actively working through their school-based learning partnerships to

integrate mental health promotion within a whole school context. The Liverpool Learning

Partnership, for example, was working with schools and partners to drive school a ‘Whole School

Approach’ to mental health, facilitating seven working groups examining issues raised by schools.

Camden Learning had established a school-led mental health learning hub in which participants used

action research methodologies to explore themes suggested by schools. The mental health learning

hub is currently developing two mental health resources; one for primary schools focusing on helpful

and unhelpful thinking; and one for secondary schools focusing on anxiety, with the aim of helping

young people to recognise when it is a problem and when it is a normal part of life and how to

develop greater resilience.

An important theme that ran through the testimony of local areas was the role that everyone in the

system needs to play in ‘normalising and not awfulizing’ common adolescent or childhood

experiences. Many of those who engaged in the fieldwork emphasised that an important part of

creating the foundations for good mental health lay in supporting children and young people to

recognise that it is normal to sometimes feel frightened, anxious or sad but that often these feelings

will be short-lived and that there are strategies that can be used to regulate difficult emotions. The

role of teachers and other staff in schools in reinforcing these messages with children and young

people, and at times also with parents, was seen as critical. In the words of one experienced clinical

psychologist supporting schools “Most of what I do is normalise things, such as routines and

boundaries.”

Local areas also recognised that being able to engage in a wide range of positive activities including

sports, outdoor activities and creative opportunities was an important component of good mental

health for all young people. For those experiencing more significant challenges with their mental

health, access to an alternative curriculum of positive activities could often be a lifeline. Many areas,

therefore, had commissioned services, often delivered by VCS partners, which provided children and

young people with opportunities to improve their mental health through art, music, caring for

animals, playing team sports or taking part in outward bound activities. These programmes had the

capacity to promote good mental health at many different levels – by providing friendship groups,

relationships with an adult they can begin to trust and rely on, opportunities for young people to

succeed and feel successful, increasing physical activity, developing communication and sometimes

through direct therapeutic inputs.

Young people with poor mental health, which manifests in disruptive behaviour, are often at greater

risk of exclusion from school. Cornwall are piloting a project through which schools can apply, to the

‘Inclusion support team programme’ for additional funding for a programme of activities to support

the child. A detailed plan about how they are going to prevent exclusion will be developed. So far

this year 86 applications were accepted, resulting in only two permanent exclusions. Children are

provided with a teacher who builds a trusting relationship with them and supports them through a

12-week intervention, often involving outdoor activities that create opportunities for modelling

good peer relationships, using positive educational activities. These include such things as

mentoring, ‘surf back to school’, or a day spent in forest activities. Children will come back to school

with the same teacher, aiming to transfer new-found confidence into the classroom. The other

important outcome of this approach are the positive effects on anxiety levels and wellbeing for

headteachers, family and class teachers. Most of the children that were involved in the programme

last year are back in their schools with less support.

There is a strong relationship between mental health and physical health. The prevalence data

shows that children and young people with poor general health are about twice as likely to also have

poor mental health as those with good general health. Some local areas were therefore beginning to

explore how to promote good mental and physical health in tandem for young people. This was

particularly important for young people suffering from long term health conditions. For example, in

Hertfordshire a core of GPs had developed and were running a service for young people with long-

term physical health problems such as diabetes which included a mental health component to

enable young people to see the link between what they were experiencing physically and the impact

this might have on them emotionally.

The Empathy Project, also delivered in Hertfordshire, is an innovative project supporting young people at A&E using young volunteers as befrienders to address emotional wellbeing and mental health. Through supportive conversations the young volunteers provide information about local services and community projects and offer practical support. The project was set up to cover two hospitals because hospital staff realised they were not set up well to cater for the needs of teenagers at what is often a vulnerable time in their lives. The peer volunteers are specially selected and trained and then supervised by Youth Workers. A clinician who led a review of the project said: “Empathy workers have relieved pressure on hospital staff, boosted the commitment of staff to prioritise mental health and emotional wellbeing, bridged gaps between A&E and specialist mental health teams and made themselves useful with practical tasks such as helping to resource the teenage corridor at the Lister Hospital.”

Developing the children’s workforce ‘Children’s mental health is everyone’s business’ was one of the phrases that we heard most

frequently when carrying out the fieldwork for this research. It encapsulates the belief that only

when all those who interact regularly with children and young people have a good understanding of

how to support their mental health needs will it be possible to make the transition from a

treatment-driven model of support to a system truly geared to early intervention.

Nurseries, schools and colleges have a unique role to play in supporting children and young people’s

mental health, because it is the professionals in these settings who see and interact with children

and young people every day. In the words of one CAMHS practitioner “Schools do most of the

mental health work in this country because they are always there. Our important task is to support

school staff.” It is not surprising then, that alongside the work to support schools to embrace the

promotion of mental health as part of their overall approach to teaching and learning, all the local

areas we engaged had also focused on providing training, support and advice to staff working in

schools and other educational settings.

Many of the local areas we visited had developed a system which enabled staff in schools, nurseries

or colleges to access rapid support and advice about the mental health of a child or young person

with whom they were working. In some areas, this took the form of a Single Point of Contact within

CAMHS whom teachers or support staff could contact for immediate advice. In other areas schools

were allocated a CAMHS link worker who would visit the school regularly (for example fortnightly) to

provide advice for staff, carry out work with individual young people, or run training or group

support sessions.

Several areas that we visited were also Mental Health Support Teams (MHST) trailblazer sites.

Camden was one of the local areas in the first wave of trailblazers and had been working on how to

develop their approach, building on a long history of engagement between their CAMHS service and

schools. They were in the process of training a new workforce at a lower level than CAMHS who

would carry out guided self-help support in schools and also support emotional regulation work

through whole class approaches. Their initial focus was on low mood and anxiety from Year 6

upwards.

In Bedford Borough the early help service recognised the need to do more to support young people

experiencing lower level mental health issues that might be affecting their behaviour, their

relationships with friends and family, or their readiness to learn. They also felt that there was more

that they could do to support young people who might be waiting for CAMHS treatment to manage

that challenging period in their lives. They therefore invested in training for two early help

practitioners to achieve a qualification in Solution Focused Therapy. This is a brief therapeutic

intervention which, as the name suggests, supports young people to visualise their goals for the

future and the solutions that they want to enact, rather than focusing on the difficulties and

challenges they are experiencing in the present. Following the successful trialling of the approach by

the early help service they have also extended the training to allow pastoral support staff and others

in schools to develop the skillset and provided discussion groups and networking opportunities for

those who have completed the training to continue to hone their skills and discuss the application of

the techniques in the context of their daily work. To date nearly 50 young people have benefitted

from solution focused brief therapy in Bedford, and in more than 80 per cent of cases young people

recorded a positive impact on their emotional wellbeing and more confidence to achieve the goals

they had set themselves.

Within the broader schools’ workforce, several local areas had a specific focus on developing access

to skilled school counsellors. The Children’s Commissioner emphasised in her 2019 report on early

access to mental health support, the important role of school counsellors in providing early

intervention and preventative support. However, in some areas there was concern about the growth

in the number of school counsellors employed directly by schools who may not have appropriate

professional accreditation or training and whose quality may not be assured. Several local

partnerships were tackling this head on. For example, Salford had developed a quality assurance

commissioning framework. The framework provides a quality assurance process for schools wishing

to commission provision around counselling which draws on feedback from professionals, young

people and parents. In Dorset the school counselling service provides accreditation for counsellors

as well as supervision and training for staff in schools.

Of course, school staff are not the only professionals that work regularly with children and young

people. The local partnerships engaged in the fieldwork had also focused on skilling up health

visitors, school nurses, social workers, foster carers, youth workers, youth offending services and

those working in the voluntary and community sector. In many cases this professional development

focuses on providing the person who has the best personal relationship with the child or young

person with the skills and techniques to begin to have supportive conversations about mental

health. Local areas spoke about the importance of reducing professional anxiety around children’s

mental health, providing practical examples of what professionals could do within the course of their

day to day work, and knowing what to look for which might indicate that more specialist help is

needed. A few specific examples illustrate these points:

• In Salford a mental health nurse, a family wellbeing practitioner and a CAMHS clinician are

embedded in the Youth Offending Service. They provide trauma informed supervision to staff

and match staff with young people to try to forge the strongest relationships. As part of

becoming a trauma-informed service they have also redesigned the space for meeting young

people. The programme is yielding subtle changes in language and thinking, for example moving

from a concept of ‘challenging behaviour’ to ‘distressed behaviour’ and embedding the idea that

behaviour is a form of communication.

• Within Hertfordshire there are children’s wellbeing practitioners, who offer one to one anxiety

and low mood interventions, group work in schools, parent training for children’s anxiety and

anxiety awareness for children.

Several local partnerships reflected that the development of the children’s workforce to promote

and support good mental health was most effective when professionals from different disciplines

and backgrounds trained alongside each other. This created a shared language and joined-up

conceptual framework. It also provided the opportunity to establish relationships between

professionals working with the same children and young people. In fact, there was growing evidence

from the fieldwork of how different professionals working in a locality might come together to

positively improve mental health outcomes for children and young people.

• In Bedford, early help practitioners, school nurses and CAMHS school link workers have

started meeting regularly to problem solve for individual children and discussed joined-up

ways of working for particular schools.

• In Liverpool, local schools wanted to better work with GPs to understand why they were

signing children off school for a range of medical reasons including mental health conditions.

So, they piloted a programme in which the GP notified the school of an impending absence.

Then both the school and the GP sent a letter to the parents saying they would like to work

together to get the child school ready. Then designed a package of support to help the child

back into school. The pilot is now being rolled out in GP clusters and can help to prevent the

over-medicalisation of mental health needs and demonstrate the impact of broader services

in providing support.

In Cornwall and the Isles of Scilly, BLOOM meetings champion a new multi-agency way of working,

making better use of skills and resources from health, social care, education and the voluntary

sector. The multi-agency group meets weekly in six areas in Cornwall and the Isles of Scilly and

provides an opportunity to discuss a child or young person with whom services are struggling. They

develop a formulation that underpins everyone’s understanding of the case and decide what would

be helpful, with specialist advice from a CAMHS clinical psychologist. The referral then goes through

Early Help so that the child does not slip through the net. The process provides opportunities for

multidisciplinary learning and prevents escalation of problems. From the schools’ perspective this

puts the needs of the child and family at the centre and allows for the development of a ‘common

language’. A recent case involved a 7-year-old boy who was on a waiting list for an autism service.

He was struggling in school and was disruptive. His teacher came along to the Bloom meeting and

was helped to develop strategies for the classroom and a plan that involved social prescribing,

including a community surfing offer. ‘BLOOM offers a way of thinking about a child differently rather

than “they don’t meet our threshold” for CAMHS’.

Even in those areas that have the most effective focus on early intervention and prevention, there

will always be some children and young people who need access to more specialist forms of mental

health support. The areas that we engaged as part of this research were in the process of

redesigning how partners come together to deliver specialist support that is timely, accessible, high

quality and in a format and setting with which children, young people and families can engage. The

three key enablers are embedding CAMHS within community settings and child-facing teams;

supporting families holistically; and developing new and creative approaches to managing the most

significant risks.

Embedded CAMHS The Director of CAMHS in Camden, and one of the co-authors of the THRIVE framework, was very clear about the conditions that should be in place to ensure a more integrated model of service delivery. These were:

• Shared clarity of ambition from commissioner and directors, and permission for staff to work

differently;

• Colocation of mental health clinicians in schools, special schools, social care, early help and

others;

• Time spent with other professionals is valuable and is ‘counted’ in commissioning terms;

• Pre-referral discussions happen routinely to avoid redundant referrals;

• Joint visits and bridging in other professionals are commonplace;

• Time is carved out for thinking together; and

• Professionals develop trusting relationships.

These principles lead to a very different model of delivering targeted and specialist mental health

interventions, with a focus on working across a broader group of professionals to develop a plan for

intervention and delivering in settings that are closer to children and young people. In Camden,

alongside a more traditionally organised community CAMHS service, there are also CAMHS clinicians

embedded in the looked after children team, children’s centres, supported housing, the Hive youth

hub, the PRU, the Youth Offending Service, the MASH and Early Help. There is also a vibrant

partnership with voluntary and community sector providers which are commissioned to provide

targeted and specialist interventions with a specific focus or cohort of young people, parents/carers

and families. The benefits of this approach to embedding and integrating clinical professionals in

non-clinical teams are the cross-fertilisation of ideas and skills between staff, the speed with which

issues can be resolved, reductions in young people not attending treatment, and reduced wastage

with fewer referrals ‘bouncing’ from one team to another.

Camden was certainly not an isolated example in moving towards a more integrated way of working.

In Salford, for example, the head of service described the bespoke and integrated CAMHS offer for

looked after children which provides a six to eight week mental health screening for every looked

after child, support on resilience, further assessment where needed, direct mental health work with

individual children and advice to children’s homes and foster carers. Hertfordshire now have four co-

located CAMHS staff in their Youth Justice services, with easy access to two consultant psychiatrists.

These CAMHS experts provide support to staff, helping them in their work with young people with

difficulties with emotional dysregulation, trauma, drug addiction and gang membership, as well as

offering quick direct access to clinical sessions for those that need to be seen.

Supporting families Children live in families, and good or poor mental health occurs in a family context. Indeed, the

prevalence data shows a strong correlation between parental mental health and child mental health,

and there is now a growing body of evidence of how important it is to address parental conflict in

order to effect change in child mental health and behaviour. Yet most mental health services still

focus on treating the individual. Many of the areas engaged in this research were beginning to

explore what holistic family-based mental health support should look like. Often this was spear-

headed by early help services which have historically developed a strengths-based and holistic

approach to supporting families.

In 2015, on the Isles of Scilly, 18 young people were receiving treatment from CAMHS out of a

population of 420 children and young people. Not only was this a high proportion of young people

given the small size of the population, but it was not best serving the interests of the young people

in question. The Isles of Scilly, due to its size and location has no CAMHS clinicians on the islands.

Therefore, the young people accessing CAMHS had to fly to Cornwall every two weeks to attend

their appointments. This was disruptive to their school and family lives and also afforded the young

people little anonymity in attending their treatment.

Children’s services on the Isles of Scilly therefore looked to construct a different offer of support for

children and young people’s mental health, focused much more on preventing issues escalating and

using the resources available on the islands to provide the support needed. They took a whole

community approach to trauma informed practice and trained children’s services and school staff in

mental health first aid and emotional resilience. They also employed an experienced Family Support

worker to work in the Isles of Scilly’s one school and trained one other member of staff in the school

to become a THRIVE practitioner. Those working with children and young people would benefit from

regular Bloom meetings of the GP, health visitor, school nurse, family support worker and children’s

services, with a CAMHS clinician providing advice by phone, to decide who was best placed to

support each child and the plan of support going forward.

The family support worker was critical in bringing about a change of culture in the school. Equally

important was the role of the family support worker in going into the community and working with

parents to develop mental health and emotional resilience in a family context. The Isles of Scilly have

also commissioned training for their workforce in domestic abuse and parental conflict and joined

up the commissioning of children and adults mental health to ensure effective transitions for young

people and also that parents experiencing mental health issues get the joined-up support they need.

Today there are only three young people on the Isles of Scilly accessing specialist CAMHS treatment.

Although the Isles of Scilly are a unique community, there are important national lessons to learn

from their experience in terms of how to intervene earlier to prevent crises developing, how to wrap

support and training around a school, and how to work with families and communities to support

mental health holistically.

In Camden they had commissioned a community-based whole family service which provided stay

and play sessions with CAMHS clinicians, evidence-based interventions such as Video Interaction

Project (VIP) and Video Interaction Guidance (VIG), therapy for couple conflict, interventions for

multi-generational trauma and access to an adult psychologist. They had also commissioned a parent

infant service for very young children (most referrals are for children under four months old) which

uses reflective practice to explore and support the relationship between child and parent. In

addition, there are members of the adult mental health team based in children’s centres to provide

psychological support to parents when needs are identified in a child.

However, local partnerships were also frank in highlighting the big gap that still exists with adults’

mental health commissioning and expressed an appetite to help shape and influence that to more

routinely consider the needs of families. For example, assessments by mental health services do not

generally take into account whether the adult receiving treatment is also a parent and what the

mental health implications for their children might be. This is a focus for further development.

Creative approaches to managing risk All the local areas we engaged in the research were wrestling with issues of how best to support

children and young people with more complex and high-risk mental health needs. In this report we

have focused predominantly on how local community-based partnerships can come together to

achieve better mental health outcomes for children in that area. We have not looked in detail,

therefore, at the complexities, costs and challenges of commissioning highly specialist in-patient

treatment for mental health disorders, although this is certainly a live issue. Instead here we are

looking at how those with more complex needs can be supported effectively within a local

community setting.

The nature of the debate on mental health, that so often pivots towards the sufficiency and

accessibility of CAMHS, risks assuming that if a child or young person with a mental health need can

get accepted for treatment then all will be well. However, it is a salutary reminder that not all

children and young people with a mental health need will benefit from CAMHS treatment. One

Director of CAMHS to whom we spoke estimated that only about 45 per cent of those referred to

CAMHS really benefit from a CAMHS intervention. This presents a systemic challenge of how to

manage the needs of children who do not make much progress and can get stuck in the system. This

can have a significant impact on overall CAMHS capacity and can frustrate ambitions to improve

access and lower waiting times.

Many of the local areas that we engaged were therefore looking at different ways of collectively

managing the risk of more complex cases. Historically these children and young people might have

been seen as the responsibility of specialist services, but with the introduction of the THRIVE

framework local partnerships were increasingly looking at how a variety of services and partners

might come together to enable, and trust, young people to look after themselves and successfully

manage their ongoing mental health condition. One practitioner described this ‘as the ability to

contain uncertainty’. Many of the approaches that local areas described were anchored in a team

convening around a young person and constructing a bespoke plan of support. In Hertfordshire, for

example, they described how the Complex Case consultation panel had really helped in cases where

there was uncertainty in how to proceed, for example in cases of harmful sexual behaviour or very

challenging behaviour linked to autism or other neurodevelopmental conditions.

Local areas were also looking to identify groups of children or young people whose needs were more

likely to escalate rapidly and co-construct different ways of working with them and their families.

One of the pressure points in many areas was for children and young people experiencing neuro-

developmental issues where waiting times for diagnoses were often very long, engagement with

parents fragmented, and access to support insufficient. Several areas were therefore working with

parents to redesign the neuro-developmental pathway, for example, bringing together professionals

such as educational psychologists, schools, paediatricians and CAMHS, widening front end support

to prevent issues escalating and reducing bureaucracy around diagnoses. In a similar vein, many

areas were also working with a broad range of professionals, children and young people and their

families to redesign crisis care pathways to ensure that sufficient access to trusted and known

support is available quickly, even out of hours.

The Greater Manchester (GM) crisis care pathway is being led by four NHS mental health providers

and has been developed and jointly commissioned by the GM health and social care partnership,

involving councils, CCGs, the VCS, health and the private sector. The pathway comprises several

areas, some of which are new service developments and some which require transformation of

existing systems and services.

Four new Rapid Response Teams launched in May 2019 and are now operating 8am to 8pm, 7 days a

week, actively supporting young people across all 10 boroughs of Greater Manchester. They provide

rapid assessment, de-escalation and brief intervention for young people who are experiencing a

mental health crisis and support young people, along with their families, for up to 72 hours. Whilst

being implemented in a phased way, the ambition is to have a 24/7 crisis response from April 2021

and to expand the points of referral over the next 12 months to ensure clear, safe and effective

pathways which reach the young people most in need of support.

Three Safe Zones have been opened across GM by a partnership of voluntary, charitable and social

enterprise organisations led by The Children’s Society. This service provides complementary and

ongoing support in a youth-centred, community setting for young people and families who have

accessed the rapid response service. There is a longer-term ambition to enable open access for

certain groups of vulnerable young people who may otherwise present more frequently to A&E.

The next 12 months will see further developments to enhance the inpatient services across the

pathway including three sites piloting the We Can Talk programme which supports effective working

between CAMHS and paediatrics; scoping for a Discharge Coordination Team primarily to support

the weekend offer; and a procurement exercise for the independent sector to provide ‘crash pads’

for young people who require a safe space for immediate risk management and de-escalation.

However, it must also be acknowledged that with very complex cases there are considerable

challenges to the system. We heard from several local areas that the providers do not exist to

sufficiently contain and support these children and young people. When placements breakdown

they struggle to find alternatives for the most vulnerable. There was concern among local areas

about the sustainability of this situation, with a significant potential impact in terms of risk and cost.

Young people can often be placed at some distance from home which has implications for visiting

and proper monitoring. Far more training and support is needed for foster carers, so that

placements are less likely to break down and at the same time long term evidence based

interventions need to be available for children with the most complex needs earlier on, to address

problems of self-harm, suicidal intentions and distressed behaviours.

Looking ahead – enabling more effective local partnership working The nine key enablers described in the preceding sections provide an insight into how effective local

partnerships can work together to improve the mental health and emotional wellbeing of all children

and young people, act early to resolve issues before they escalate, and provide more timely,

accessible and joined-up care for those with more complex needs. There is clearly a lot that local

government and its partners can do, even within the limitations of the current system, to improve

mental health and emotional wellbeing for children and young people. It is hoped that the key

enablers set out in this report can provide a framework against which councils, and their partners in

commissioning and delivery of mental health, might assess themselves and take action on the back

of that assessment.

However, there is a limit to what local government and its partners can do unaided. To turn around a

system plagued by a history of underfunding, shortages in the key workforces, rapidly rising demand

and a weak focus on early intervention requires concerted and coordinated action at a national

level. This is not solely about making more funding available, although that undoubtedly is needed,

but about making the most of the resources currently in the system. The following

recommendations for national government to work with local government are made with that aim

in mind:

Recommendations for national government (DfE, DHSC and NHS) 1. Set clear targets for the whole system which incentivise the investment in earlier

intervention and prevention and focus on achieving better mental health outcomes for all

children and young people.

2. Develop a consistent outcomes-focused dataset, to be used across local government and

CCGs to measure progress against the targets.

3. Set clearer expectations around strategic cooperation between CCGs and local government

for children’s mental health and give greater leverage to health and wellbeing boards to

ensure that this is acted upon.

4. Move away from pilot funding and ring-fenced grants to recurrent funding, giving more

flexibility to local partnerships to develop solutions that build on their local context.

5. Develop clearer specifications for the effective commissioning of universal mental health

provision.

6. Create stronger expectations of joined up planning, commissioning and delivery between

children and adults’ mental health, with a core focus on supporting families holistically and

managing transition for young people between adults and children’s services.

7. Review the sufficiency of the national workforce for children’s psychology (EPs, CAMHS, and

others) and create opportunities for joint professional training between educational

psychologists and CAMHS clinicians.

8. Consider how the national curriculum and school accountability system might be geared to

encourage more secure development of good mental health and to minimise the current rise

in anxiety-related issues.

9. Research and promote best practice in working with the cohort of very hard to place

adolescents and those with the most complex needs being supported in their communities

including developing a best practice offer of training and support for foster carers.

Annex A – Profiles of fieldwork areas

Bedford Bedford Borough is a relatively small unitary authority which was created in 2009 as part of a wider

reorganisation of local government. It is a borough with slightly lower than average levels of

deprivation but a relatively high concentration of children speaking English as an additional

language. Bedfordshire CCG covers Bedford Borough, Luton and Central Bedfordshire local

authorities. The contract with the East London Foundation Trust for providing mental health

services, including CAMHS, also spans these three geographies. At times this can add a layer of

complexity to commissioning arrangements. However, the local authority and the CAMHS provider

both underlined the strength of their relationship with each other and the platform this has

provided to develop a more preventative approach to children’s mental health. This is underpinned

by a joint commitment to real consultation and engagement of children and young people as a

means to reshaping and improving services.

Recently, working together, Bedford Borough and the CAMHS provider have established a single

point of entry for referrals for mental health, which enables a multi-agency approach to triaging risk

and allocating cases. This is having an impact on reducing waiting times, stripping out duplication

and improving the quality and consistency of decision-making.

A cornerstone of the approach to children and young people’s mental health in Bedford has been

close working with schools. The CAMHS provider has a school team which comprises 6 practitioners

across 36 schools who offer fortnightly in-school sessions covering assessment, treatment for lower-

level issues and staff consultations. The school nursing service also offers four to six sessions of

emotional health and wellbeing support on a drop-in model in senior schools and run joint clinics

with CAMHS. The Early Help service has also trained up practitioners in offering solution-focussed

therapy which it offers to young people through its strong relationship with schools. This strong

support network around schools is reinforced through additional early intervention services

commissioned from CHUMS and Relate.

A further characteristic of the Bedford approach to children and young people’s mental health is the

focus that has been placed on staff development. In addition to the professional training offered to

early help practitioners in solution focused therapy, CAMHS practitioners also offer joint training

opportunities with early help practitioners including hosting half-day events every six months and

regular talks and podcasts.

Going forward the priorities for Bedford include reducing waiting times for support, increasing the

percentage of early help referrals which have a focus on mental health, supporting adolescents at

risk and developing a ‘discovery college’ for young people with mental health issues giving access to

positive activities, sports and broader learning opportunities.

Camden Camden is an Inner London borough with extremes of both wealth and deprivation. Support for

children and young people’s mental health has been a priority for the council and its partners for

many years, and the local area benefits from the presence of several mental health organisations, in

both the statutory and community sectors, with significant national standing. These include, for

example, the Tavistock and Portman NHS Foundation Trust and the Anna Freud Centre.

Partnership working is central to Camden’s approach to supporting children and young people’s

mental health. The council and the Tavistock and Portman Foundation trust have been working

closely together in co-designing and delivering services for over a decade. The current approach to

commissioning and delivering children and young people’s mental health is captured in Camden’s

CAMHS transformation plan which was first written in 2015 and has been updated annually since

then. There is an integrated commissioning team in place which includes both council and CCG

funded posts. This team oversees the commissioning of children and young people’s health and

community support services from a budget pooled under a section 75 agreement. High-level

governance of outcomes for children and young people’s mental health is exercised firstly through

the CYP Mental Health Programme Group accountable to the governing body of the CCG, the

council’s executive and political governance structures and the Health and Wellbeing board.

The Tavistock and Portman Foundation Trust and the Anna Freud Centre worked together to

develop the THRIVE framework which has been adopted across many local areas to support better

joined-up working at the frontline. Unsurprisingly, therefore, Camden was one of the first places to

use the THRIVE framework to drive their approach to integrated commissioning and delivery, with a

strong focus on trying to meet need in a more preventative way. Key to this has been the

longstanding model of support for schools which has been an integral part of the Camden approach.

In terms of the operational model, a distinctive feature of support for children and young people’s

mental health in Camden is the extent to which CAMHS practitioners are embedded in a wide range

of teams which support children and families, including the Children in Need teams, the Looked

After Children team, Early Help, supported accommodation, targeted youth services and YOS.

Camden has recently been announced as a trailblazer site for both the Mental Health School teams

and four week waiting time pathfinders. Delivering on these opportunities is a key focus for the

partnership over the next period, as is continuing to increase access to support for children and

young people’s mental health, commissioning a more local response to the need for tier 4 provision

and tackling pressures around knife crime and youth violence.

Cornwall Cornwall became a unitary authority in 2007, bringing together Cornwall County Council and the six

borough and district councils in Cornwall. On average, Cornwall and the Isles of Scilly gain around

1,000 additional children and young people between the ages of 0-15 annually through families

moving into the area and have a higher rate of child poverty than the national average. Around 40

per cent of residents live in small settlements with populations under 3,000, therefore rural isolation

and poor transport links impact on service accessibility.

Cornwall covers a large footprint and local partners across all agencies in health, education, social

care and the voluntary sector have come together, with the Isles of Scilly, to develop and implement

their strategic plan called ‘One Vision’ for Children and Young People. The plan was developed

following extensive engagement with professionals, children, young people, parents and carers.

Their priorities involve a commitment to joint commissioning with an integrated commissioning

board, a proactive approach to children and young people with adverse childhood experiences,

providing timely access to early help for those with escalating problems and protecting children who

are at risk from harm from parents with mental health problems and alcohol and drug addiction.

Cornwall are using the iThrive framework and the iThrive partnership meetings bring together the

council, the CCG, schools, higher education, further education, CAMHS public health and primary

care to provide a really rounded view of children and young people’s mental health and emotional

wellbeing. Those involved in the partnership reflected both on the significant benefits that

partnership working is now delivering and the amount of time it had taken to build relationships and

trust – it has been a two-year journey.

An important consequence of adopting the iThrive framework is that commissioners have moved

away from activity-based contracts to outcomes-based specifications, aligned with the iThrive

framework dimensions. This has involved a deliberative and iterative planning process with partners

to get the pathways and outcomes measures right. The next priority will be to create more

opportunities for collective commissioning through mechanisms such as joint supplier services

events.

Cornwall is one of the Mental Health Teams in Schools trailblazers which forms a significant priority

for the next period. They have also received big lottery funding for three years for their HeadStart

Kernow programme to deliver resilience and mental wellbeing focussed on children and young

people between the ages of 10-16, based on a trauma informed approach.

Dorset Dorset underwent a large-scale council reorganisation last year, bringing together the 9 councils

under two unitary authorities; Bournemouth Christchurch and Poole, and Dorset council. This has

had a significant impact. There is one CCG covering the whole of Dorset.

Children’s services are currently being transformed and emotional wellbeing and mental health is a

priority, with a commitment to collaborative working across all partners in health, social care and

education. Their vision emphasises building resilience and early help, considering the needs of the

whole family. There is a joint children and young people’s mental health steering group which

includes providers and commissioners across health and social care, feeding into the CCG

programme board and CAMHS provider board. They use the THRIVE model to map pathways and

develop services and are a trailblazer site for mental health support teams in schools.

There are six community multi-disciplinary CAMHS teams which comprise psychiatrists,

psychologists, occupational therapists, behavioural support workers and social workers. There is also

an all-age eating disorder service and an out of hours crisis service. Beyond this core offer, Dorset

and its partners are looking at how they reshape their perinatal and infant mental health offer, for

example piloting training in Cognitive Analytic Therapy for parents. They are also taking support for

mental health out into the community. They have codesigned workshops for young people on

general mental health and exam stress which are delivered by a peer specialist and CAMHS

professional in a community environment. This has enabled them to engage young people who

would not normally access services in a medical setting. They are also working with the third sector

to engage ‘hard to reach’ young people with activities from kayaking to speedboating.

The work of the educational psychology service is also an important part of the children and young

people’s mental health offer in Dorset. They have rolled out ‘I can problem solve’ – an early

intervention programme designed to address the risk factors associated with anti-social behaviour,

drug use or poor mental health. The educational psychology service has also made available an

online survey for children and staff based on a resilience framework that gives schools an insight into

the issues they need to address within their school and staff populations.

Priorities for Dorset moving forward include building on a trauma-informed approach to mental

health in schools; mapping and assuring the quality of counselling provision in schools; and rolling

out a new system of triage and brief interventions for children and young people with lower-level

mental health needs.

Hertfordshire Hertfordshire covers a very large and complex geographical area, with two CCGs and ten district and

borough councils. There are three NHS provider trusts, covering acute and community services and

one mental health trust. There are about 500 schools and a population of approximately 1.2 million,

with over 250,000 young people below the age of 18.

Five years ago, Hertfordshire, as a system, carried out a review of children and young peoples’

mental health services across all CCGs and the council and collaboratively developed a

transformation plan. This plan involved investment and many services have expanded. Hertfordshire

are an iThrive accelerator site, so they developed an integrated solution to work towards embedding

the Thrive principles and methodology across all emotional wellbeing and mental health services.

They have a children’s integrated commissioning executive- involving multi agency services including

police, schools and health, running across the whole of the county. Collectively they have developed

an outcomes dashboard which enables them to monitor progress in mental health at both an

individual and population level.

In response to rising demand for support for children and young people’s mental health,

Hertfordshire has recently carried out a demand and capacity review in order to understand the

causes underlying increased demand and to develop more integrated solutions, with more of a focus

on early help. The council and its partners are now reshaping many of their services, with the

support and oversight of the Health and Wellbeing board. They have recommissioned their

Children’s Centres as ‘family centres’ with health visitors and school nurses integrated into the offer.

All staff have a clear mental health component to their work. They have invested in the voluntary

and community sector to deliver earlier and more preventative interventions; they are taking a

public health approach to understanding causes of stress and building resilience; and working with

young people to develop mental health ‘peer champions’.

In common with many areas, Hertfordshire have also been working with schools to promote holistic

approaches to supporting good mental health. They have developed a Kite Mark with clear criteria

to recognise good practice in relation to the whole school approach to promoting good mental

health and emotional wellbeing. Further, Hertfordshire is one of the sites that received funding to

deliver the school based Mental Health Support Teams, which is currently being rolled out across

two district areas. They have also invested in their school nursing service to support mental health in

schools through text messaging ‘chat health’ and offering training as well as individual and group

interventions.

Isles of Scilly The Isles of Scilly is a small island community which presents unique opportunities and challenges for

children and young people’s mental health. With fewer than 500 children and young people living on

the island, and a single all-through school, there is a very tight-knit community. In many ways this

can provide a wonderfully nurturing environment for children to grow up in. But it can also present

its own challenges. For teenagers, for example, beginning to experiment with their independence, it

can be difficult to make normal adolescent mistakes without everybody knowing about it. Small year

groups and a tightly defined peer group can also mean that emotional issues become amplified.

In commissioning terms, the Isles of Scilly form part of the Cornwall CCG. The CCG has recognised

that commissioning for the Isles of Scilly requires a bespoke approach and therefore provides an

agreed budget every year that can be used flexibly for early intervention and prevention. It also

makes training available in mental health issues to those working on the islands, and commissions

CAMHS to provide phone support around decision-making on individual cases. The small population

also means a small children’s workforce, so training is vital to develop what the DCS calls ‘expert

generalists’ – a cadre of professionals working with children who can confidently interact and

support on a wide range of specialist topics.

A particular feature of the approach to children and young people’s mental health on the Isles of

Scilly has been the way in which they have wrapped support and training around the school and

focused on embedding a preventative approach with pupils, staff and parents. This has enabled a

whole-community discourse around good mental health and emotional wellbeing, supported

through a facebook site and other materials around children’s wellbeing.

A further feature has been the commitment to bringing professionals together to find a joint

solution to issues as they arise. Using the Bloom approach, those working with children on the Isles

of Scilly are supported to have regular child and family-centred discussions that can unblock issues

and use the resource available to best effect. One of the advantages of working in a small island

community is that the relevant professionals can often be convened within an hour of an issue

occurring. Avoiding crises through better early intervention and prevention of course takes on a

greater immediacy and urgency in the context of the Isles of Scilly where access to specialist services

on the mainland can be frustrated due to poor weather or if a child or young person is not well

enough to fly.

Going forward, priorities for the Isles of Scilly include building on the community-based aspects of

their work, skilling up parents as champions of mental health and supporting young people to help

and look out for each other. Their ambition is to become the most ‘mentally aware’ community in

the country.

Liverpool Liverpool is a large metropolitan council with high levels of deprivation. The provision and support

for mental health and wellbeing in Liverpool is largely conducted through their CAMHS partnership

which is comprised of specialist, in-patient CAMH services delivered by the Alder Hey Trust, broader

provision and advice delivered by the Young People Advisory Service (YPAS) and other smaller,

specialist voluntary community sector (VCS) organisations. The bulk of funding for these comes from

the CCG, with some investment from the council and some Lottery funding. Those who took part in

the research felt that the journey they had been on in developing their CAMHS partnership and the

CCG commissioning partnership has created a way for health and non-health providers to feel

involved. This facilitates the sense of distributed responsibility throughout the system.

YPAS makes up a large part of mental health and wellbeing support. It is a registered charity set up

to support children and young people with Tier 2 and Tier 3 needs and is largely delivered through

three ‘YPAS Plus Community Hubs’ across Liverpool. The service supports children and young people

through from 0 to 25 years and also conducts work with parents, with an emphasis on bringing

mental health awareness and support out into the community. The types of services offered out of

the YPAS Hubs include counselling, drop-ins, information and guidance and more specialist services.

In Liverpool, there is also a significant focus on working with schools to support better mental health

and wellbeing. In primary schools, Liverpool has developed the Whole School Approach (WSA)

working with representatives from the Liverpool Learning Partnership, CAMHS Partnership, CCG, the

local authority, children/young people, families and universities. The Whole School Approach

reinforces the ways in which good mental health can be built into schools’ curriculum, ethos,

leadership, physical space and governance. To support primary schools, there are 7 working groups

to bring schools together; 3 mental health support teams (MHSTs) to provide a link between schools

and hubs; training available for leads as educational mental health practitioners; and a tool (in

development) to assist schools in identifying needs and the relevant support service. For secondary

schools, Liverpool has developed Wellbeing Clinics which provide a close link into YPAS and also

offer training to SENCOs in needs identification.

Salford Salford is an average sized metropolitan council with high levels of deprivation. It is part of the

Greater Manchester combined authority and both significantly contributes to and benefits from this

wider partnership in terms of developing its approach to children and young people’s mental health.

Salford was an early adopter of the THRIVE framework and has used this to reconfigure their

commissioning and services. The THRIVE network meetings provide a vibrant governance structure

which brings a very wide variety of both statutory and VCS partners, commissioners and service

deliverers together to plan collaboratively. There is an integrated commissioning team in place,

appointed jointly by the CCG and the council and pooled budget arrangements which enable a more

flexible approach to funding and pathways.

Support for children and young people’s mental health and wellbeing in Salford comprises work with

universal services, such as settings, schools, health visitors, school nurses, early help practitioners

and GPs to better identify mental health needs and provide holistic interventions for emotional

wellbeing; early intervention and preventative therapeutic support delivered by the VCS

organisation 42nd Street; and more specialist and/or in-patient provision delivered by CAMHS. The

more specialist interventions include support for looked-after-children, provision for young people in

the Youth Offending Service and specific CAMHS interventions for 16-17-year olds with the

programme Emerge. The mental health offer for looked after children is particularly well-embedded.

Salford Therapeutic and Referral for Looked After Children (STARLAC) is commissioned by the CCG

and monitored by the Local Authority. The service provides a direct CAMHS screening and support

service for children in care, provides training for social care staff and delivers parenting courses.

Manchester and Salford Eating Disorder Service (MSEDS) is jointly commissioned with Manchester

Health and Care Commissioning and delivered by Manchester Foundation Trust. It provides a specialist

eating disorder service for children and young people in line with national requirements. The service

has consistently met or exceeded the national standards for access and waiting times and was held up

as the gold standard in a Greater Manchester review of children and young people’s eating disorder

services in 2019.

Salford are also promoting a whole school approach to mental health and wellbeing through rolling

out Emotionally Friendly Schools, the CAMHS Schools Link Programme and work on post-16 policies.

Emotionally Friendly Schools offers primary and secondary schools and settings whole school

awareness training and action planning meetings. Schools, as part of this, can gain different

accreditations based on the training received. Currently, early years and post-16 versions are being

developed. The CAMHS School Link programme acts as a CAMHS offer of training, liaison and

consultation for schools and provides targeted interventions in schools delivered by qualified

children and young people’s wellbeing practitioners, who support children identified at risk of

experiencing difficulties during transition from primary to secondary school. CAMHS Link schools

have access to bespoke packages of support and specific projects with Educational Psychology, 42nd

Street and Year 6-7 transition services. This is all part of a shift away from the need for diagnosis and

supporting schools to be more trauma-informed throughout their curriculum and pedagogy.

Salford is currently working on expanding mental health support to all schools, early years and post

16 settings, developing the concept of THRIVE aligned early help and family support hubs, moving

from activity focused to outcome focused commissioning, developing and embedding its new

support offer for the LGBTQ+ community of young people and working with the city’s large

Orthodox Jewish communities to develop culturally aware and sensitive approaches to supporting

emotional wellbeing.